第百九十五条の三（給与所得者の特定親族特別控除申告書）
Article 195-3Salary Income Earner's Return for Special Deduction for Specified Relatives
国内において給与等の支払を受ける居住者は、第百九十条（年末調整）に規定する過不足の額の計算上、同条第二号ホに掲げる特定親族特別控除の額に相当する金額の控除を受けようとする場合には、その給与等の支払者（二以上の給与等の支払者から給与等の支払を受ける場合には、主たる給与等の支払者）からその年最後に給与等の支払を受ける日の前日までに、次に掲げる事項を記載した申告書を、当該給与等の支払者を経由して、その給与等に係る所得税の第十七条（源泉徴収に係る所得税の納税地）の規定による納税地の所轄税務署長に提出しなければならない。
If a Resident paid a salary or other wage in Japan seeks to receive a deduction of the amount equivalent to the special deduction for specified relatives set forth in item (ii), (e) of Article 190 (Year-End Adjustment) in calculating the amount of the excess or shortfall prescribed in that Article, the Resident must submit a declaration stating the following particulars to the competent district director for the locality for paying over taxes under Article 17 (Locality for Paying Over Withholding Tax) for the income taxes on that salary or other wage, via the person paying that salary or other wage (or, if the Resident is paid salaries or other wages by two or more persons paying a salary or other wage, the principal payer of salary), by the day before the day on which the Resident is paid the last salary or other wage for the year by that payer:
当該給与等の支払者の氏名又は名称
the name of that person paying the salary or other wage;
第八十四条の二第一項（特定親族特別控除）に規定する特定親族（次項において「特定親族」という。）の氏名及び個人番号（個人番号を有しない者にあつては、氏名）並びにその者のその年の合計所得金額又はその見積額並びにその者が非居住者である親族である場合にはその旨
the name and individual number (or, for a person without an individual number, the name) of each specified relative as prescribed in Article 84-2, paragraph (1) (Special Deduction for Specified Relatives) (referred to as a "specified relative" in the following paragraph), that person's total income for the year or its estimated amount, and, if that person is a relative who is a Nonresident, a statement to that effect;
その他財務省令で定める事項
any other particulars specified by Ministry of Finance Order.
前項の規定による申告書に特定親族が非居住者である親族である旨の記載をした居住者は、政令で定めるところにより、当該記載がされた者が当該居住者の親族に該当する旨を証する書類及び当該記載がされた者が当該居住者と生計を一にすることを明らかにする書類を提出し、又は提示しなければならない。
A Resident who has stated in a declaration under the preceding paragraph that a specified relative is a relative who is a Nonresident must, pursuant to Cabinet Order, submit or present a document certifying that the person about whom that statement has been made is a relative of the Resident and a document showing that the living expenses of the person about whom that statement has been made are paid from the same resources as the Resident.
第一項の規定による申告書は、給与所得者の特定親族特別控除申告書という。
A declaration under paragraph (1) is referred to as a salary income earner's return for special deduction for specified relatives.