参考様式第５－７号
Reference Form 5-7

報 酬 支 払 証 明 書
Proof of Payment of Remuneration

月分（ 月 日から 月 日 分）の報酬について、以下のとおり支払いました。
The remuneration for the month of (from DD/MM to DD/MM) was paid as follows.

１　対象労働者
The worker for whom the payment was made
① 氏名（ローマ字）
Name (Roman letters)

②性　別
Sex
sex) && $record->sex == '0') ? 'checked' : '' }} {{ $type == 'detail' ? 'disabled' : '' }}>
sex) && $record->sex == '1') ? 'checked' : '' }} {{ $type == 'detail' ? 'disabled' : '' }}>
③生　年　月　日
Date of birth

④国籍・地域
Nationality/Region

⑤在留カード番号
Residence Card No.

2. 報酬
Remuneration
①報　酬　総　額
Total amount of remuneration
円
Yen
②現　金　支　給　額
Amount paid in cash
円
Yen
③支　　給　　日
Payment date
年 / Year 月 / Month 日 / Day
（注意）
1　上記2①は、控除前の報酬総額を記載すること。
2　上記2②は、控除後の手取り報酬額を記載すること。
上記の記載内容は、事実と相違ありません。
(Notes)
1　The total amount of remuneration before deductions must be stated in ① of section 2 above.
2　The amount of take-home pay after deductions must be stated in ② of section 2 above.
I hereby declare that the statement given above is true and correct.
年 / Year 月 / Month 日 / Day
特定技能所属機関の氏名又は名称
Name of the organization of affiliation of the specified skilled worker
作成責任者　役職・氏名
Name and title of the person responsible for preparing this document
給与支給者　役職・氏名
Name and title of the salary payer

報酬について、雇用条件書どおりの報酬額であることを確認し十分に理解した上で、上記の内容どおり支給を受けました。

I have checked and fully understood that the amount of remuneration is just the same as what is stated in the Written Employment Conditions, and have received the above payment of remuneration.

年 / Năm 月 / Tháng 日 / Ngày
技能実習生の署名
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