別添３（航空）
1 / 2
<AIR/EXP>
代表統番
XXXE
輸出者
申告種別
XXXX
区分
XXX E
あて先税関
XXXXXXXXXE
提出先
申告年月日
XE
yyyy/MM/dd
申告条件[ X ]
申告番号
XXX XXXX XX1E
搬入[ X ]
XXXXXXXX-X1XE XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXXXXXX4XXXXXXXXX5XXXXXXXXX6XXXXXXXXXE
住所
XXXXXXE
電話
XXXXXXXXX1E
9999999999& 999999999999999999999999999999999999999999999999999999999999999&
⛯㛵஦ົ⟶⌮ே
XXXXXXXXX1XXXXE XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXXXXXX4XXXXXXXXX5XXXXXXXXX6XXXXXXXXXE
ཷ⌮␒ྕ
仕向人
住所
代理人
999999999&
XXXXXXXX-X1XE XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXXXXXX4XXXXXXXXX5XXXXXXXXX6XXXXXXXXXE
XXXXXXXXE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
国コード XE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
通関士コード XXXXE
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXXXXXX4XXXXXXXXXE
XXXXE
ＡＷＢ番号
保税地域
最終仕向地
積込港
出港予定年月日
XXX-XXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
XXXXE XXXXXXXXX1XXXXXXXXXE
XXXXE XXXXXXXXX1XXXXXXXXXE
貨物個数
XXXXE XXXXXXXXX1XXXXXXXXXE
yyyy/MM/dd
貿易形態別符号
㍺ฟᢎㄆド➼༊ศ XE
㍺ฟᢎㄆド␒ྕ➼
999& 999999999999999999&
(1) XXXE 999999999999999999& 999& 999999999999999999&
(2) XXXE 999999999999999999& 999& 999999999999999999&
(3) XXXE 999999999999999999& 999& 999999999999999999&
(4) XXXE 999999999999999999& 999& 999999999999999999&
(5) XXXE 999999999999999999& 999& 999999999999999999&
999& 999999999999999999& 999& 999999999999999999&
999& 999999999999999999& 999& 999999999999999999&
12,345,678 個
事前検査済貨物等識別[ X ]
船積(搭載)確認
調査用符号
XXE
XXXXE
(関税[ X ] 内国消費税[ X ] その他[ X ])
仕入書番号
X仕入書番号(電子)
仕入書価格 XXE ＦＯＢ価格
通貨レート XXE ＢＰＲ合計
XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXE
XXXXXXXXXE
XXE - 123,456,789,012,345,678 - X
XXE - 123,456,789,012,345,678
123456789
XXE - 123456789
123,456,789,012,345,678 - X
構成 12
記事（税関）
記事（通関）
記事（荷主）
社内整理番号
枚
12
欄
JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJ7J
JJJJJJJJ8JJJJJJJJJ9JJJJJJJJJ0JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJE
JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE
JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE
XXXXXXXXX1XXXXXXXXXE 利用者整理番号 XXXXE
税関通知欄
JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJJJJJ4JJJJJJJJJ5JJJJJJJJJ6JJJJJJJJJE
許可年月日
yyyy/MM/dd
JJJJJJJJJ1JJJJJJJJJ2JJJJJJJJJ3JJJJJE
保税運送承認期間 yyyy/MM/dd ～ yyyy/MM/dd
(注)この申告に基づく処分について不服があるときは、その処分があったことを知った日の翌日から起算して
２月以内に税関長に対して異議申立てすることができます。
＜ XE 欄＞ 統合先欄 XE
品名 XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXXXXXXE
申告価格（ＦＯＢ） \1,234,567,890,123
( \1,234,567,890,123 )
価格再確認[ X ]
統計品目番号
XXXX.XX-XXE X
数量(1)
123,456,789,012 XXXE
数量(2)
123,456,789,012 XXXE
ＢＰＲ按分係数
123,456,789,012,345,678
ＢＰＲ金額
XXE - 123,456,789,012,345,678
輸出令別表 XXXXE
外為法第48条[ X ]
関税法70条関係(1) XE (2) XE (3) XE (4) XE (5) XE
減免戻税条項符号 XXXXE
(法)
(令)
JJJJJE
JJJJJJJJJ1JJJJJJJJJ2JJJJJE
JJJJJJJJJ1JJJJJJJJJ2JJJJJE
内消税免税符号
X- X
JJJJJJJJJ1JJJJJJJJJ2JE
＜ XE 欄＞ 統合先欄 XE
品名 XXXXXXXXX1XXXXXXXXX2XXXXXXXXX3XXXXXXXXXE
申告価格（ＦＯＢ） \1,234,567,890,123
( \1,234,567,890,123 )
価格再確認[ X ]
統計品目番号
XXXX.XX-XXE X
数量(1)
123,456,789,012 XXXE
数量(2)
123,456,789,012 XXXE
ＢＰＲ按分係数
123,456,789,012,345,678
ＢＰＲ金額
XXE - 123,456,789,012,345,678
輸出令別表 XXXXE
外為法第48条[ X ]
関税法70条関係(1) XE (2) XE (3) XE (4) XE (5) XE
減免戻税条項符号 XXXXE
(法) JJJJJJJJJ1JJJJJJJJJ2JJJJJE (令) JJJJJJJJJ1JJJJJJJJJ2JJJJJE
JJJJJE
内消税免税符号
X- X
JJJJJJJJJ1JJJJJJJJJ2JE
別添３（海上）
6($(;3!
௦⾲⤫␒
999&
㍺ฟ⪅
ఫᡤ
㟁ヰ
⛯㛵஦ົ⟶⌮ே
ཷ⌮␒ྕ
⏦࿌✀ู
99 99
༊ศ
999&
9999999999&
࠶࡚ඛ⛯㛵
999999999&
ᥦฟඛ
⏦࿌ᖺ᭶᪥
9&
ZZZZ..EE
⏦࿌᮲௳> 9 @
999999999999999999999999999999999999999999999999999999999999999&
999999&
999999999&
9999999999&
999999999&
௙ྥே
ఫᡤ
9999999999&
99999999&
௦⌮ே
9999&
9999999999999&9999999999999999999999999999999&
9999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
ᅜࢥ࣮ࢻ 9&
9999999999999999999999999999999&
㏻㛵ኈࢥ࣮ࢻ 9999&
999999999999999999999999999999999999999999999&
㍺ฟ⟶⌮␒ྕ 9999999999999999999999999999999&
㸿㹕㹀␒ྕ
9999999999999999999999999999999&
㈌≀ಶᩘ
㈌≀㔜㔞
ಖ⛯ᆅᇦ
᭱⤊௙ྥᆅ
✚㎸ 
஦๓᳨ᰝ῭㈌≀➼㆑ู> 9 @
㈠᫆ᙧែู➢ྕ 99&
9999&
9999&
⏦࿌␒ྕ
999999999&
ᦙධ> 9 @
999999999999999999&
999999999999999999&
99&
99&
9999& 999999999999999999&
ㄪᰝ⏝➢ྕ
9999&
✚㍕ணᐃ⯪ᶵྡ 99999999& 9999999999999999999999999999999&
ฟ ணᐃᖺ᭶᪥
⯪✚ᦚ㍕☜ㄆ 㛵⛯> 9 @ෆᅜᾘ㈝⛯> 9 @ࡑࡢ௚> 9 @
ZZZZ..EE
999999999999999999999999999999999999999999999999999999999999999
グྕ␒ྕ
999999999999999999999999999999999999999999999999999999999999999&
㍺ฟᢎㄆド➼༊ศ 9&
㍺ฟᢎㄆド␒ྕ➼
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
9
௙ධ᭩␒ྕ㟁Ꮚ
௙ධ᭩౯᱁ 99& 㹄㹍㹀౯᱁
㏻㈌࣮ࣞࢺ 99& ௙ධ᭩␒ྕ
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
999& 999999999999999999&
㹀㹎㹐ྜィ
9999999999999999999999999999999&
999999999&
99& 9
99& 99& 9
ᵓᡂ ᯛ ḍ
9999999999&
9999999999& 9999999999& 9999999999& 9999999999&
999999999999999999999999999999999999999999999999999999999999999&
ఫᡤ
9999999999999& 9999999999999999999999999999999&
9999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
ࢥࣥࢸࢼᮏᩘ
ᮏ
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
グ஦㸦⛯㛵㸧
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++&
グ஦㸦㏻㛵㸧
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++&
グ஦㸦Ⲵ୺㸧
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++&
♫ෆᩚ⌮␒ྕ
999999999999999999& ฼⏝⪅ᩚ⌮␒ྕ 9999& Ⲵ୺ࣜࣇ࢓ࣞࣥࢫ␒ྕ 9999999999999999999999999999999&
ࣂࣥࢽࣥࢢሙᡤ
⛯㛵㏻▱ḍ
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++&
ZZZZ..EE
チྍᖺ᭶᪥
++++++++++++++++++++++++++++++++&
ಖ⛯㐠㏦ᢎㄆᮇ㛫 ZZZZ..EE 㹼 yyyyMMdd ཪࡣ㐠㏦㈌≀ࡢⓎ㏦ࡢ᪥ࢆ㉳⟬᪥࡜ࡍࡿྠᮇ㛫
ὀࡇࡢ⏦࿌࡟ᇶ࡙ࡃฎศ࡟ࡘ࠸࡚୙᭹ࡀ࠶ࡿ࡜ࡁࡣࠊࡑࡢฎศࡀ࠶ࡗࡓࡇ࡜ࢆ▱ࡗࡓ᪥ࡢ⩣᪥࠿ࡽ㉳⟬ࡋ࡚
㸰᭶௨ෆ࡟⛯㛵㛗࡟ᑐࡋ࡚␗㆟⏦❧࡚ࡍࡿࡇ࡜ࡀ࡛ࡁࡲࡍࠋ
㸺 9& ḍ㸼 ⤫ྜඛḍ 9&
ရྡ 999999999999999999999999999999999999&
⏦࿌౯᱁㸦㹄㹍㹀㸧 =
= ౯᱁෌☜ㄆ> 9 @
⤫ィရ┠␒ྕ
99999999& 9
ᩘ㔞
999&
ᩘ㔞
999&
㹀㹎㹐ᣨศಀᩘ
㹀㹎㹐㔠㢠
99& ㍺ฟ௧ู⾲ 9999&
እⅭἲ➨᮲> 9 @
㛵⛯ἲ᮲㛵ಀ 9& 9& 9& 9& 9&
ῶචᡠ⛯᮲㡯➢ྕ 9999&
ἲ +++++++++++++++++++++++& ௧ +++++++++++++++++++++++&
+++++&
ෆᾘ⛯ච⛯➢ྕ
9 9
+++++++++++++++++++&
別添３（航空）
$IR,03!
௦⾲⛯␒
999& 9
࠶࡚ඛ⛯㛵
999999999&
༊ศ
999&
⏦࿌✀ู
9 9 >9@
99&
>9@
⏦࿌᮲௳
㍺
ධ
⪅
9999999999&
ఫ
ᡤ
999999&
㟁 ヰ
税関事務管理人
受 理 番 号 ㍺ධྲྀᘬ⪅
௙ ฟ ே
ఫ ᡤ
㍺ฟࡢጤク⪅
௦ ⌮ ே
ＡＷＢ␒ྕ
ＭＡＷＢ␒ྕ
取 卸  
✚ ฟ ᆅ
✚ ㍕ ᶵ ྡ
ධ ᖺ᭶᪥
999999999&
9999999999&
9999-99-9XX&
9999999999&
9999999999&
99999999&
㒊㛛
9&
⏦࿌␒ྕ
999999999&
⏦࿌ᖺ᭶᪥
ZZZZ..EE
⏦࿌ணᐃᖺ᭶᪥
ᮏ⏦࿌ >9@
ZZZZ..EE
999999999999999999999999999999999999999999999999999999999999999&
999999999999X& 9999999999999999999999999999999&
9999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999& 9&
9999999999999999999999999999999999999999999999999999999999999997X&
9999&
㏻㛵ኈࢥ࣮ࢻ 9999&
999999999999999999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
999999999999999999&
9999&
999999999999999999&
9999&
9999999999999999999999999999999&
ZZZZ..EE
㍺ධᢎㄆド
㈠᫆⟶⌮௧ >9@
>9@
9&
㛵⛯ἲ᮲㛵ಀチྍᢎㄆ
9&
9&
ඹ㏻⟶⌮␒ྕ
999999999&
㣗 ရ
9 999999999&
᳜ 㜵
9 99999999999999&
9 999999999&
ື ᳨
㍺ධᢎㄆド␒ྕ➼
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
ཎ⏘ᆅド᫂ >9@
ᡠ⛯⏦࿌ >9@
⛯⛉┠
9 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
9 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
9 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
999&
999&
999&
999&
999&
9&
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
ෆᐜⅬ᳨⤖ᯝ >9@
ḍᩘ
/&
/&
/&
㸫 ෆᅜᾘ㈝⛯➼
ㄢ⛯ᶆ‽㢠
ZZZZ..EE
99&
9999&
⣡⛯㢠ྜィ
ᢸ ಖ 㢠
ཱྀ ᗙ
⣡௜᪉ἲ
=
=
>9@ 㒔㐨ᗓ┴
9&
>9@
㏻㈌࣮ࣞࢺ
99& 99& 99& ᵓ ᡂ
////////&
////////&
////////&
/&ᯛ /&ḍ
9999 9999&
9
౯᱁෌☜ㄆ >9@
999&
999&
999&
999&
㍺ධ௧ู⾲
999&
≉ᜨ >9@
㹀㹎㹐ᣨศಀᩘ
㹀㹎㹐㔠㢠
99& ⶶ⨨✀ู >9@
㐠㈤ᣨศ >9@
ཎ⏘ᆅ 9& 999999& 999&
஦๓ᩍ♧ศ㢮 99999999E
事前教示ཎ⏘ᆅ 999999E
ရ┠␒ྕ
ᩘ㔞㸦㸯㸧
ᩘ㔞㸦㸰㸧
ㄢ⛯ᶆ‽ᩘ㔞
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
=
=
9999999999999999999999&
=
=
=
✀ู
999999999&
999&
ㄢ⛯ᶆ‽ᩘ㔞
999&
ῶච⛯ 99&
᮲㡯 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
=
=
9999999999999999999999&
=
=
=
999999999&
✀ู
ㄢ⛯ᶆ‽ᩘ㔞
999&
999&
ῶච⛯ 99&
᮲㡯 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㸫 ෆᅜᾘ㈝⛯➼
ㄢ⛯ᶆ‽㢠
⛯⋡
⛯㢠
ῶච⛯㢠
9999& 999999999999999999&
9999& 999999999999999999&
9
௙ධ᭩␒ྕ
9999999999999999999999999999999&
999999999&
௙ධ᭩㟁Ꮚ㸧
99& 99& 9
௙ධ᭩౯᱁
㐠 ㈤
99& 9
99999E
9
ಖ 㝤
99& 99&
㏻㛵㔠㢠
ホ ౯
9 9999999999&
9999999999&
9999999999&
999999999&
99& 99&
⿵ ṇ
9 9&999999999999999999XXXXXXXXX3XXXX&
9 9&999999999999999999XXXXXXXXX3XXXX&
9 9&999999999999999999XXXXXXXXX3XXXX&
஦๓ᩍ♧ホ౯1 999999E
஦๓ᩍ♧ホ౯2
999999E
9
㹀㹎㹐ྜィ
ィ⟬
>9@
㸺 9& ḍ㸼⤫ྜඛḍ 9&
ရྡ
999999999999999999999999999999999999&
⛯⾲␒ྕ 99999999999999999&
⏦࿌౯᱁㸦㹁㹇㹄㸧
=
=
9 9999999999999999999999&
㛵⛯⋡
㛵⛯㢠
=
ῶච⛯㢠
=
=
9999& ㍫㍫㍫㍫ ἲ ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫
ῶච⛯
௧ ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫
ู⾲ ㍫㍫㍫㍫㍫㍫㍫㍫
⛯⋡
⛯㢠
ῶච⛯㢠
ಖ⛯ᆅᇦ
搬入予定
᭱ึⶶධᖺ᭶᪥
㈠᫆ᙧែู➢ྕ
ㄪᰝ⏝➢ྕ
9&
⛯㢠ྜィ
=
=
=
99&
235689 99&
㈌≀ಶᩘ
㈌≀㔜㔞
グ஦⛯㛵 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫㍫㍫㍫㍫㍈㍫㍫㍫㍫㍫㍫㍫㍫㍫㍉
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍊㍫㍫㍫㍫㍫㍫㍫㍫㍫㍋㍫㍫㍫㍫㍫㍫㍫㍫㍫㍌㍫㍫㍫㍫㍫㍫㍫㍫㍫㍃㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍘
グ஦㏻㛵 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫ ฼⏝⪅ᩚ⌮␒ྕ 9999&
グ஦Ⲵ୺ ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫ ♫ෆᩚ⌮␒ྕ 9999&999999999999999999&
㹙⛯㛵㏻▱ḍ㹛
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫㍫㍫㍫㍫㍈㍫㍫㍫㍫㍫㍫㍫㍫㍫㍉
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍊㍫㍫㍫㍫㍫㍫㍫㍫㍫㍋㍫㍫㍫㍫㍫㍫㍫㍫㍫㍌㍫㍫㍫㍫㍫㍫㍫㍫㍫㍃㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫㍫㍫㍫㍫㍈㍫㍫㍫㍫㍫㍫㍫㍫㍫㍘
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍺ධチྍ᪥ ZZZZ..EE
ᑂᰝ⤊஢᪥ ZZZZ..EE
஦ᚋᑂᰝ 9&
㸦ὀ㸧ࡇࡢ⏦࿌࡟ᇶ࡙ࡃฎศ࡟ࡘ࠸࡚୙᭹ࡀ࠶ࡿ࡜ࡁࡣࠊࡑࡢฎศࡀ࠶ࡗࡓࡇ࡜ࢆ▱ࡗࡓ᪥ࡢ⩣᪥࠿ࡽ㉳⟬ࡋ࡚㸰᭶௨ෆ࡟⛯㛵㛗࡟ᑐࡋ࡚␗㆟⏦❧࡚を
することができます
㸦ὀ㸧ࡇࡢ⏦࿌࡟ࡼࡿㄢ⛯ᶆ‽ཪࡣ⣡௜ࡍ࡭ࡁ⛯㢠࡟ㄗࡾࡀ࠶ࡿࡇ࡜ࡀࢃ࠿ࡗࡓ࡜ࡁࡣࠊಟṇ⏦࿌ཪࡣ᭦ṇࡢㄳồࢆࡍࡿࡇ࡜ࡀ࡛ࡁࡲࡍࠋ
ࠉࠉࠉ࡞࠾ࠊ㍺ධࡢチྍᚋࠊ⛯㛵㛗ࡢㄪᰝ࡟ࡼࡾࠊࡇࡢ⏦࿌࡟ࡼࡿ⛯㢠➼ࢆ᭦ṇࡍࡿࡇ࡜ࡀ࠶ࡾࡲࡍࠋ
別添３（海上）
6($,03!
༊ศ
999&
⏦࿌✀ู
9 9 >9@
99&
௦⾲⛯␒
999& 9
࠶࡚ඛ⛯㛵
999999999&
>9@
⏦࿌᮲௳
㍺
㒊㛛
9&
⏦࿌ணᐃᖺ᭶᪥
⪅
9999999999&
999999999999999999999999999999999999999999999999999999999999999&
ᡤ
ヰ
999999&
999999999&
9999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
㍺ධྲྀᘬ⪅
௙ ฟ ே
ఫ ᡤ
ᮏ⏦࿌ >9@
ZZZZ..EE
ධ
税関事務管理人 9999999999&
受 理 番 号
9999-99-9XX&
⏦࿌␒ྕ
999999999&
⏦࿌ᖺ᭶᪥
ZZZZ..EE
ఫ
㟁
9999999999&
9999999999&
99999999&
999999999999999999999999999999999999999999999999999999999999999&
999999999999999999999999999999999999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999& 9&
9999999999999999999999999999999999999999999999999999999999999997X&
9999&
㏻㛵ኈࢥ࣮ࢻ 9999&
999999999999999999999999999999999999999999999&
㍺ฟࡢጤク⪅
௦ ⌮ ே
㹀㸭㹊␒ྕ
ࢥࣥࢸࢼᮏᩘ
ㄪᰝ⏝➢ྕ
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
9999999999999999999999999999999&
999999999999999999999999999999999&
୍ᣓ⏦࿌
>9@
//&ᮏ
㈠᫆ᙧែู➢ྕ
99&
9999&
㍺ධᢎㄆド
㈠᫆⟶⌮௧ >9@
>9@
9&
㛵⛯ἲ᮲㛵ಀチྍᢎㄆ
9&
9&
ඹ㏻⟶⌮␒ྕ
999999999&
㣗 ရ
9 999999999&
᳜ 㜵
9 99999999999999&
9 999999999&
ື ᳨
㍺ධᢎㄆド␒ྕ➼
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
999& XXXXXXXXX1XXXXXXXXXE
ཎ⏘ᆅド᫂ >9@
ᡠ⛯⏦࿌ >9@
⛯⛉┠
9 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
9 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
9 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
999&
999&
999&
999&
999&
9&
9&
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
XXXXXXXXX1XXXXXXXXXE
ෆᐜⅬ᳨⤖ᯝ >9@
⛯㢠ྜィ
=
=
=
ḍᩘ
/&
/&
/&
㈌≀ಶᩘ
㈌≀㔜㔞
✚㍕⯪ᶵྡ
ಖ⛯ᆅᇦ
99& ⯪༺  9999&
999999999999999999&
999999999999999999&
235689 99& ✚ฟᆅ 9999&
99999999&
9999999999999999999999999999999&
ZZZZ..EE
9999& 999999999999999999&
ධ ᖺ᭶᪥
ZZZZ..EE
᭱ึⶶධᖺ᭶᪥
グྕ␒ྕ
999999999999999999999999999999999999999999999999999999
999999999999999999999999999999999999999999999999999999
999999999999999999&
9
௙ධ᭩␒ྕ
9999999999999999999999999999999&
999999999&
௙ධ᭩㟁Ꮚ㸧
99& 99& 9
௙ධ᭩౯᱁
㐠 ㈤
99& 9
99999&
9
ಖ 㝤
99& 99&
㏻㛵㔠㢠
9999999999&
9999999999&
ホ ౯
9 9999999999&
999999999&
99& 99&
⿵ ṇ
9 9&999999999999999999XXXXXXXXX3XXXX&
9 9&999999999999999999XXXXXXXXX3XXXX&
9 9&999999999999999999XXXXXXXXX3XXXX&
஦๓ᩍ♧ホ౯1 999999E
஦๓ᩍ♧ホ౯2
999999E
9
㹀㹎㹐ྜィ
ィ⟬
>9@
⣡⛯㢠ྜィ
ᢸ ಖ 㢠
ཱྀ ᗙ
⣡௜᪉ἲ
㸺 9& ḍ㸼⤫ྜඛḍ 9&
ရྡ
999999999999999999999999999999999999&
⛯⾲␒ྕ 99999999999999999&
⏦࿌౯᱁㸦㹁㹇㹄㸧
=
=
9 9999999999999999999999&
㛵⛯⋡
㛵⛯㢠
=
ῶච⛯㢠
=
=
9999& ㍫㍫㍫㍫ ἲ ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫
ῶච⛯
௧ ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫
ู⾲ ㍫㍫㍫㍫㍫㍫㍫㍫
㸫 ෆᅜᾘ㈝⛯➼
ㄢ⛯ᶆ‽㢠
⛯⋡
⛯㢠
ῶච⛯㢠
㏻㈌࣮ࣞࢺ
99& 99& 99& ᵓ ᡂ
////////&
////////&
////////&
/&ᯛ /&ḍ
9999 9999&
9
౯᱁෌☜ㄆ >9@
999&
999&
999&
999&
㍺ධ௧ู⾲
999&
≉ᜨ >9@
㹀㹎㹐ᣨศಀᩘ
㹀㹎㹐㔠㢠
99& ⶶ⨨✀ู >9@
㐠㈤ᣨศ >9@
ཎ⏘ᆅ 9& 999999& 999&
஦๓ᩍ♧ศ㢮 99999999E
事前教示ཎ⏘ᆅ 999999E
ရ┠␒ྕ
ᩘ㔞㸦㸯㸧
ᩘ㔞㸦㸰㸧
ㄢ⛯ᶆ‽ᩘ㔞
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
=
=
9999999999999999999999&
=
=
=
✀ู
999999999&
999&
ㄢ⛯ᶆ‽ᩘ㔞
999&
ῶච⛯ 99&
᮲㡯 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫
=
=
9999999999999999999999&
=
=
=
999999999&
✀ู
ㄢ⛯ᶆ‽ᩘ㔞
999&
999&
ῶච⛯ 99&
᮲㡯 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㸫 ෆᅜᾘ㈝⛯➼
ㄢ⛯ᶆ‽㢠
⛯⋡
⛯㢠
ῶච⛯㢠
=
=
>9@ 㒔㐨ᗓ┴
9&
>9@
グ஦⛯㛵 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫㍫㍫㍫㍫㍈㍫㍫㍫㍫㍫㍫㍫㍫㍫㍉
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍊㍫㍫㍫㍫㍫㍫㍫㍫㍫㍋㍫㍫㍫㍫㍫㍫㍫㍫㍫㍌㍫㍫㍫㍫㍫㍫㍫㍫㍫㍃㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍘
グ஦㏻㛵 ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫ ฼⏝⪅ᩚ⌮␒ྕ 9999&
グ஦Ⲵ୺ ㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫ ♫ෆᩚ⌮␒ྕ 9999&999999999999999999&
㹙⛯㛵㏻▱ḍ㹛
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫㍫㍫㍫㍫㍈㍫㍫㍫㍫㍫㍫㍫㍫㍫㍉
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍊㍫㍫㍫㍫㍫㍫㍫㍫㍫㍋㍫㍫㍫㍫㍫㍫㍫㍫㍫㍌㍫㍫㍫㍫㍫㍫㍫㍫㍫㍃㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍆㍫㍫㍫㍫㍫㍫㍫㍫㍫㍇㍫㍫㍫㍫㍫㍫㍫㍫㍫㍈㍫㍫㍫㍫㍫㍫㍫㍫㍫㍘
㍫㍫㍫㍫㍫㍫㍫㍫㍫㍄㍫㍫㍫㍫㍫㍫㍫㍫㍫㍅
㍺ධチྍ᪥ ZZZZ..EE
ᑂᰝ⤊஢᪥ ZZZZ..EE
஦ᚋᑂᰝ 9&
㸦ὀ㸧ࡇࡢ⏦࿌࡟ᇶ࡙ࡃฎศ࡟ࡘ࠸࡚୙᭹ࡀ࠶ࡿ࡜ࡁࡣࠊࡑࡢฎศࡀ࠶ࡗࡓࡇ࡜ࢆ▱ࡗࡓ᪥ࡢ⩣᪥࠿ࡽ㉳⟬ࡋ࡚㸰᭶௨ෆ࡟⛯㛵㛗࡟ᑐࡋ࡚␗㆟⏦❧࡚を
することができます
㸦ὀ㸧ࡇࡢ⏦࿌࡟ࡼࡿㄢ⛯ᶆ‽ཪࡣ⣡௜ࡍ࡭ࡁ⛯㢠࡟ㄗࡾࡀ࠶ࡿࡇ࡜ࡀࢃ࠿ࡗࡓ࡜ࡁࡣࠊಟṇ⏦࿌ཪࡣ᭦ṇࡢㄳồࢆࡍࡿࡇ࡜ࡀ࡛ࡁࡲࡍࠋ
ࠉࠉࠉ࡞࠾ࠊ㍺ධࡢチྍᚋࠊ⛯㛵㛗ࡢㄪᰝ࡟ࡼࡾࠊࡇࡢ⏦࿌࡟ࡼࡿ⛯㢠➼ࢆ᭦ṇࡍࡿࡇ࡜ࡀ࠶ࡾࡲࡍࠋ

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