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["扶養状況確認票　兼　必要書類チェック票(子)"]
[]
["◆左欄にすべて☑・記入し、回答に応じた必要書類を添付のうえご提出ください。(必ず添付した必要書類のチェック欄に☑してください)"]
["◆この用紙は、被扶養者認定基準を満たしているかを判断する書類ですので、必ず事実に基づいてご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名コード"]
["◆未記入や不足書類がある場合、差し戻し等で審査に時間を要します。"]
["◆必要に応じて内容の問合せや、追加書類を求める場合があります。"]
["1.基本情報(被保険者本人と、扶養に入れる子についてご記入ください)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要書類"]
["氏名",null,null,null,null,null,null,"続柄",null,null,null,"年齢",null,"職業・学年",null,null,null,null,"居住区分",null,null,null,null,null,null,null,"【全員必須】"]
[null,null,null,null,null,null,null,"被保険者\n(本人)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住民票の原本"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(世帯全員分、続柄・筆頭者記載のもの)"]
[null,null,null,null,null,null,null,null,null,null,null,"歳",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※90日以内に発行されたもの"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同居 ・ 単身赴任 ・ 別居",null,null,null,null,null,null,null,"【学生の場合 ※高校生以下は不要】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"学生証(有効期限の記載必須)の写し"]
[null,null,null,null,null,null,null,null,null,null,null,"歳",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【18歳以上の場合】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所得証明書または非課税証明書の原本"]
[null,null,null,"続柄は詳しく記載してください(例：長男、三女、養子　など)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(役所で発行の最新年度分)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※90日以内に発行されたもの"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【別居の場合(単身赴任除く)  ※遠方進学の学生は不要】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別居家族状況記入書(健保HPより入手)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"仕送り証明書の写し　直近3か月分"]
["2.扶養申請の理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要書類"]
[null,null,"1)被保険者(あなた)の入社・異動"]
[null,null,"2)出生"]
[null,null,"3)退職",null,null,"(退職日：",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",")",null,null,null,null,null,null,"以下のいずれか１点"]
[null,null,"★失業給付について➜",null,null,null,null,null,null,"受給中",null,null,"受給予定",null,null,null,"受給終了(",null,null,null,"年",null,"月",null,"日",")",null,null,"・退職証明書\n・健康保険資格喪失証明書\n・雇用保険離職票(写し)\n・雇用保険資格喪失確認通知書(写し)"]
[null,null,"理由",null,null,null,"A)出産・育児による退職"]
[null,null,null,null,null,null,"B)傷病による退職➜",null,null,null,null,null,"傷病手当金",null,null,null,"受給中",null,null,"受給予定",null,null,null,"受給終了"]
[null,null,null,null,null,null,"C)一身上の都合、会社都合など"]
[null,null,"4)その他　↓扶養申請するに至った理由をできるだけ詳細に記入"]
[null,null,"＜理由＞"]
["3.これまで加入していた(している)健康保険　※出生の場合、記入不要"]
[null,null,"1)被保険者(あなた)の扶養に入っていた"]
[null,null,"2)他の家族の扶養に入っていた ➜",null,null,null,null,null,null,null,null,null,null,"(子からみた続柄：",null,null,null,null,null,null,null,null,null,")",null,null,null,"2)","他の家族が村田健保の加入者であった場合"]
[null,null,"3)子が勤務先で加入していた",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 ","その家族の氏名コード:"]
[null,null,"4)国民健康保険",null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,")","市区町村"]
[null,null,"5)任意継続被保険者",null,null,null,null,null,null,null,null,"村田健保の任意継続",null,null,null,null,null,null,null,"その他の任意継続"]
["4.被保険者(あなた)の配偶者の状況"]
[null,null,"配偶者なし",null,null,null,"理由",null,null,null,"1)離別　➜　養育費",null,null,null,null,null,null,null,null,null,null,null,"円／年",null,null,null,"※配偶者なしの場合、住民票の筆頭者表記または\n   戸籍謄本等での確認を行います"]
[null,null,null,null,null,null,null,null,null,null,"2)死別・未婚"]
[null,null,"配偶者あり"]
[null,null,null,null,"1)健康保険の扶養に入っている もしくは今回子と同時に申請中"]
[null,null,null,null,"2)健康保険の扶養に入っていない(配偶者が自身で加入中)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※後日、事実との大幅な相違が確認できた際には、",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"→2)の場合は、夫婦双方の育休取得有無・見込収入をご記入ください",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　遡って削除させて頂く場合があります。"]
[null,null,null,null,null,null,null,null,"育児休業(産後休暇含む)取得予定",null,null,null,null,null,null,null,null,null,null,null,null,"今後1年間の見込収入"]
[null,null,null,null,"被保険者",null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,"収入種別に○➜(",null,null,null,null,"給与",null,"・","自営業",null,"・","育休給付金",null,null,null,"・","その他",null,")",null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,"あり ➜ 期間",null,null,null,"(",null,null,"年",null,null,"か月)",null,"収入額➜(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円／年)",null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"配偶者",null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,"収入種別に○➜(",null,null,null,null,"給与",null,"・","自営業",null,"・","育休給付金",null,null,null,"・","その他",null,")",null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,"あり ➜ 期間",null,null,null,"(",null,null,"年",null,null,"か月)",null,"収入額➜(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円／年)",null,null,null,null,null,null,null,null,null,false]
["\n"]
["↓以下18歳未満は記入不要↓"]
["5.子の今後１年間の見込収入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要書類"]
[null," ※下記いずれかに必ずチェックを入れてください"]
[null,null,null,null,"収入なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➜","金額の記入不要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"給与収入のみ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➜","1)に金額を記入、2)～7)は記入不要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"給与収入以外の収入 または 給与収入＋給与収入以外の収入 あり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➜","1)～7)の\"全て\"に金額を記入(収入無の項目は0円)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
["1)給与(パート・アルバイト含む)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月額",null,null,null,null,null,null,null,null,null,"円",null,null,"労働条件通知書 等"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※労働条件通知書等を提出できない場合は\n　　「給与明細書の写し：直近３か月分」　または\n　　「就労状況証明書(健保HPで入手)」　を提出"]
["2)年金(種類：",null,null,null,null,null,null,null,null,null,null,null,null,null,")","年額",null,null,null,null,null,null,null,null,null,"円",null,null,"年金改定通知書\nまたは年金振込通知書の写し(直近分)"]
["3)自営業収入(農・商・漁・販売・他)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,null,null,null,null,null,null,null,null,"円",null,null,"確定申告書第一表・第二表および収支内訳書(損益計算書)の写し　直近３年分"]
["4)家賃・不動産等の収入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,null,null,null,null,null,null,null,null,"円"]
["5)株の配当金・利子等の収入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,null,null,null,null,null,null,null,null,"円",null,null,"　※『直接的必要経費申告書』 は希望者のみ提出\n　　　詳細は健保HPにてご確認ください"]
["6)傷病手当金、労災の休業補償",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日額",null,null,null,null,null,null,null,null,null,"円",null,null,"支給額を証明するものの写し(給付金決定通知書等)"]
["7)その他継続性のある収入(内容：",null,null,null,null,null,null,null,null,null,null,null,null,null,")","月額",null,null,null,null,null,null,null,null,null,"円",null,null,"収入額が分かるものの写し"]
["※個人情報の保護について　：　この情報は健康保険の事業のみの利用とし、その他の目的には使用致しません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"R8.5"]

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["扶養状況確認票　兼　必要書類チェック票(子)"]
[]
["◆左欄にすべて☑・記入し、回答に応じた必要書類を添付のうえご提出ください。(必ず添付した必要書類のチェック欄に☑してください)"]
["◆この用紙は、被扶養者認定基準を満たしているかを判断する書類ですので、必ず事実に基づいてご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名コード"]
["◆未記入や不足書類がある場合、差し戻し等で審査に時間を要します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MM00000"]
["◆必要に応じて内容の問合せや、追加書類を求める場合があります。"]
["1.基本情報(被保険者本人と、扶養に入れる子についてご記入ください)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要書類"]
["氏名",null,null,null,null,null,null,"続柄",null,null,null,"年齢",null,"職業・学年",null,null,null,null,"居住区分",null,null,null,null,null,null,null,"【全員必須】"]
["村田　太郎",null,null,null,null,null,null,"被保険者\n(本人)",null,null,null,50,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住民票の原本"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(世帯全員分、続柄・筆頭者記載のもの)"]
[null,null,null,null,null,null,null,null,null,null,null,"歳",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※90日以内に発行されたもの"]
["村田　セイサク",null,null,null,null,null,null,"二男",null,null,null,20,null,"アルバイト",null,null,null,null,"同居",null,null,null,null,null,null,null,"【学生の場合 ※高校生以下は不要】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"学生証(有効期限の記載必須)の写し"]
[null,null,null,null,null,null,null,null,null,null,null,"歳",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【18歳以上の場合】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所得証明書または非課税証明書の原本"]
[null,null,null,"続柄は詳しく記載してください(例：長男、三女、養子　など)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(役所で発行の最新年度分)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※90日以内に発行されたもの"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【別居の場合(単身赴任除く)  ※遠方進学の学生は不要】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別居家族状況記入書(健保HPより入手)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"仕送り証明書の写し　直近3か月分"]
["2.扶養申請の理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要書類"]
[null,null,"1)被保険者(あなた)の入社・異動"]
[null,null,"2)出生"]
[null,null,"3)退職",null,null,"(退職日：",null,null,null,"R8",null,null,"年",4,null,null,"月",30,null,null,"日",")",null,null,null,null,null,null,"以下のいずれか１点"]
[null,null,"★失業給付について➜",null,null,null,null,null,null,"受給中",null,null,"受給予定",null,null,null,"受給終了(",null,null,null,"年",null,"月",null,"日",")",null,null,"・退職証明書\n・健康保険資格喪失証明書\n・雇用保険離職票(写し)\n・雇用保険資格喪失確認通知書(写し)"]
[null,null,"理由",null,null,null,"A)出産・育児による退職"]
[null,null,null,null,null,null,"B)傷病による退職➜",null,null,null,null,null,"傷病手当金",null,null,null,"受給中",null,null,"受給予定",null,null,null,"受給終了"]
[null,null,null,null,null,null,"C)一身上の都合、会社都合など"]
[null,null,"4)その他　↓扶養申請するに至った理由をできるだけ詳細に記入"]
[null,null,"＜理由＞"]
["3.これまで加入していた(している)健康保険　※出生の場合、記入不要"]
[null,null,"1)被保険者(あなた)の扶養に入っていた"]
[null,null,"2)他の家族の扶養に入っていた ➜",null,null,null,null,null,null,null,null,null,null,"(子からみた続柄：",null,null,null,null,null,null,null,null,null,")",null,null,null,"2)","他の家族が村田健保の加入者であった場合"]
[null,null,"3)子が勤務先で加入していた",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 ","その家族の氏名コード:"]
[null,null,"4)国民健康保険",null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,")","市区町村"]
[null,null,"5)任意継続被保険者",null,null,null,null,null,null,null,null,"村田健保の任意継続",null,null,null,null,null,null,null,"その他の任意継続"]
["4.被保険者(あなた)の配偶者の状況"]
[null,null,"配偶者なし",null,null,null,"理由",null,null,null,"1)離別　➜　養育費",null,null,null,null,null,null,null,null,null,null,null,"円／年",null,null,null,"※配偶者なしの場合、住民票の筆頭者表記または\n   戸籍謄本等での確認を行います"]
[null,null,null,null,null,null,null,null,null,null,"2)死別・未婚"]
[null,null,"配偶者あり"]
[null,null,null,null,"1)健康保険の扶養に入っている もしくは今回子と同時に申請中"]
[null,null,null,null,"2)健康保険の扶養に入っていない(配偶者が自身で加入中)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※後日、事実との大幅な相違が確認できた際には、",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true]
[null,null,null,null,"→2)の場合は、夫婦双方の育休取得有無・見込収入をご記入ください",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　遡って削除させて頂く場合があります。"]
[null,null,null,null,null,null,null,null,"育児休業(産後休暇含む)取得予定",null,null,null,null,null,null,null,null,null,null,null,null,"今後1年間の見込収入"]
[null,null,null,null,"被保険者",null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,"収入種別に○➜(",null,null,null,null,"給与",null,"・","自営業",null,"・","育休給付金",null,null,null,"・","その他",null,")",null,null,null,null,null,null,true]
[null,null,null,null,null,null,null,null,null,"あり ➜ 期間",null,null,null,"(",null,null,"年",null,null,"か月)",null,"収入額➜(",null,null,null,6000000,null,null,null,null,null,null,null,null,null,null,"円／年)",null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"配偶者",null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,"収入種別に○➜(",null,null,null,null,"給与",null,"・","自営業",null,"・","育休給付金",null,null,null,"・","その他",null,")",null,null,null,null,null,null,true]
[null,null,null,null,null,null,null,null,null,"あり ➜ 期間",null,null,null,"(",null,null,"年",null,null,"か月)",null,"収入額➜(",null,null,null,2000000,null,null,null,null,null,null,null,null,null,null,"円／年)",null,null,null,null,null,null,null,null,null,false]
["\n"]
["↓以下18歳未満は記入不要↓"]
["5.子の今後１年間の見込収入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要書類"]
[null," ※下記いずれかに必ずチェックを入れてください"]
[null,null,null,null,"収入なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➜","金額の記入不要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"給与収入のみ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➜","1)に金額を記入、2)～7)は記入不要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,"給与収入以外の収入 または 給与収入＋給与収入以外の収入 あり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➜","1)～7)の\"全て\"に金額を記入(収入無の項目は0円)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true]
["1)給与(パート・アルバイト含む)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月額",null,50000,null,null,null,null,null,null,null,"円",null,null,"労働条件通知書 等"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　※労働条件通知書等を提出できない場合は\n　　「給与明細書の写し：直近３か月分」　または\n　　「就労状況証明書(健保HPで入手)」　を提出"]
["2)年金(種類：",null,null,null,null,null,null,null,null,null,null,null,null,null,")","年額",null,0,null,null,null,null,null,null,null,"円",null,null,"年金改定通知書\nまたは年金振込通知書の写し(直近分)"]
["3)自営業収入(農・商・漁・販売・他)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,100000,null,null,null,null,null,null,null,"円",null,null,"確定申告書第一表・第二表および収支内訳書(損益計算書)の写し　直近３年分"]
["4)家賃・不動産等の収入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,0,null,null,null,null,null,null,null,"円"]
["5)株の配当金・利子等の収入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,0,null,null,null,null,null,null,null,"円",null,null,"　※『直接的必要経費申告書』 は希望者のみ提出\n　　　詳細は健保HPにてご確認ください"]
["6)傷病手当金、労災の休業補償",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日額",null,0,null,null,null,null,null,null,null,"円",null,null,"支給額を証明するものの写し(給付金決定通知書等)"]
["7)その他継続性のある収入(内容：",null,null,null,null,null,null,null,null,null,null,null,null,null,")","月額",null,0,null,null,null,null,null,null,null,"円",null,null,"収入額が分かるものの写し"]
["※個人情報の保護について　：　この情報は健康保険の事業のみの利用とし、その他の目的には使用致しません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"R8.5"]