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["正",null,null,null,null,"健康保険　被扶養者（異動）届",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"常務理事",null,null,"事務(局)長",null,null,"部長",null,null,"課長",null,null,"課長補佐",null,null,"担当者"]
[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,null,null,null,null,null,null,null,null,null,null,"・黄色部分に入力、チェックして印刷してください。入力、チェックされた箇所は、",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"副","に反映されます。"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・印刷する際は、「A４　両面（長辺綴じ）」で印刷してください。白黒でもカラーでも結構です。"]
["令和",null,null,"年",null,"月",null,"日","提出",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,null,"・セルを結合したり、列や行を追加・削除しないでください。リセットボタンが正常に動作しなくなります。"]
["提出者記入欄",null,null,null,"　届書記入の個人番号に誤りがないことを確認しました。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・ご使用のプリンターにより、A４用紙に納まらない場合は列や行を追加・削除するのではなく、"]
[null,"事業所\n所在地",null,null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険の記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　以下の方法で対応してください。"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　1）余白を調整する。"]
[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,null,null,null,null,null,null,null,null,null,null,"　　2）印刷を拡大・縮小する。"]
[null,"事業所\n名　称",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,null,null,null,null,null,null,null,null,"　　3）空欄の「行」の高さを調整する"]
[]
[null,"事業主\n氏　名",null,null,"　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　\n　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"社会保険労務士記載欄"]
[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　　等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"前回入力した情報を保存している場合は、別人の情報が残るのを避けるため"]
[null,"電話番号",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,null,null,null,null,null,null,null,null,"下のリセットボタンを押して、全て消去してから入力してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"→"]
[]
[]
["被保険者欄","①",null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,"④"]
[null,"被保険者等番号",null,null,null,null,null,null,null,"(ﾌﾘｶﾞﾅ)",null,"(氏)",null,null,null,null,null,null,null,"(名)",null,null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,null,"性別\n(ﾌﾟﾙﾀﾞｳﾝ)"]
[null,null,null,null,null,null,null,null,null,"氏 名"]
[]
[null,"⑤",null,null,null,null,null,null,null,null,null,null,null,"⑥",null,null,null,null,null,null,"⑦",null,null,"〒"]
[null,"取　得\n年月日",null,null,null,null,null,null,null,null,null,null,null,"標準報酬\n月　　額",null,null,null,null,null,null,"住 所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"千円"]
[null,"被扶養者でない配偶者が",null,null,null,null,null,null,null,"いる",null,"1．いるの場合、年収見込をご記入ください",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※配偶者以外の同居の家族を扶養に追加する場合にご記入ください。"]
[null,null,null,null,null,null,null,null,null,"いない",null,"配偶者の年収見込額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円"," 配偶者の追加には、収入確認書類が必要になる場合があります。(副本裏面参照)"]
["※被扶養者の「該当」と「非該当」は同時に提出できません。「該当」、「非該当」はそれぞれ別の用紙で提出してください。"]
["被扶養者になった場合は「該当」、被扶養者でなくなった場合は「非該当」を〇で囲んでください。"]
["被扶養者欄１","①",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,null,null,"回収区分","添付\n\n返不能\n\n滅失"]
[null,"(フリガナ)\n\n氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号"]
[null,null,null,null,"(氏)",null,null,null,null,null,"(名)",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,{"$f":"ChkD!F2","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",null,null,null,null,"⑤",null,null,null,null,null,"⑥",null,null,"同居","〒"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"続 柄",null,null,null,null,null,"住 所"]
[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,false,"別居"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ﾌﾟﾙﾀﾞｳﾝ)"]
[null,"該　当",null,null,"⑦",null,null,null,null,null,null,null,null,null,"⑧",null,null,"無職",null,null,"小・中学生以下",null,null,null,null,"⑨",null,null,null,null,null,null,null,"⑩",null,null,"新規（被保険者の取得）"]
[null,null,null,null,"被扶養者に\nなった日",null,null,null,null,null,null,null,null,null,"職 業",null,null,"パート",null,null,"高・大学生(",null,null,null,"年生)","収入\n(年収)",null,null,null,null,null,null,null,"理 由",null,false,"婚姻",null,null,"出生",null,null,"収入減"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年金受給者",null,false,"その他(",null,null,null,")",null,null,null,null,null,null,null,"円",null,null,null,"離職",null,null,"その他（",null,null,null,")"]
[null,"非該当",null,null,"⑪",null,null,null,null,null,null,null,null,null,"⑫",null,null,"死亡","(令和",null,"年",null,"月",null,"日)","⑬",null,null,null,null,null,null,null,"⑭",null,null,null,null,null,"発行が必要"]
[null,null,null,null,"被扶養者で\nなくなった日",null,null,null,null,null,null,null,null,null,"理 由",null,null,"就職",null,null,"収入増",null,null,"離婚",null,"備 考",null,null,null,null,null,null,null,"資格確認書\n発行要否"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達 ",null,null,"その他(",null,null,null,")"]
[]
["被扶養者欄２","①",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,null,null,"回収区分","添付\n\n返不能\n\n滅失"]
[null,"(フリガナ)\n\n氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号"]
[null,null,null,null,"(氏)",null,null,null,null,null,"(名)",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,{"$f":"ChkD!F3","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",null,null,null,null,"⑤",null,null,null,null,null,"⑥",null,null,"同居","〒"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"続 柄",null,null,null,null,null,"住 所"]
[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,"別居"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ﾌﾟﾙﾀﾞｳﾝ)"]
[null,"該　当",null,null,"⑦",null,null,null,null,null,null,null,null,null,"⑧",null,null,"無職",null,null,"小・中学生以下",null,null,null,null,"⑨",null,null,null,null,null,null,null,"⑩",null,null,"新規（被保険者の取得）"]
[null,null,null,null,"被扶養者に\nなった日",null,null,null,null,null,null,null,null,null,"職 業",null,null,"パート",null,null,"高・大学生(",null,null,null,"年生)","収入\n(年収)",null,null,null,null,null,null,null,"理 由",null,null,"婚姻",null,null,"出生",null,null,"収入減"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年金受給者",null,null,"その他(",null,null,null,")",null,null,null,null,null,null,null,"円",null,null,null,"離職",null,null,"その他（",null,null,null,")"]
[null,"非該当",null,null,"⑪",null,null,null,null,null,null,null,null,null,"⑫",null,null,"死亡","(令和",null,"年",null,"月",null,"日)","⑬",null,null,null,null,null,null,null,"⑭",null,null,null,null,null,"発行が必要"]
[null,null,null,null,"被扶養者で\nなくなった日",null,null,null,null,null,null,null,null,null,"理 由",null,null,"就職",null,null,"収入増",null,null,"離婚",null,"備 考",null,null,null,null,null,null,null,"資格確認書\n発行要否"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達 ",null,null,"その他(",null,null,null,")"]
[]
["被扶養者欄３","①",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,null,null,"回収区分","添付\n\n返不能\n\n滅失"]
[null,"(フリガナ)\n\n氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号"]
[null,null,null,null,"(氏)",null,null,null,null,null,"(名)",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,{"$f":"ChkD!F4","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",null,null,null,null,"⑤",null,null,null,null,null,"⑥",null,null,"同居","〒"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"続 柄",null,null,null,null,null,"住 所"]
[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,"別居"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ﾌﾟﾙﾀﾞｳﾝ)"]
[null,"該　当",null,null,"⑦",null,null,null,null,null,null,null,null,null,"⑧",null,null,"無職",null,null,"小・中学生以下",null,null,null,null,"⑨",null,null,null,null,null,null,null,"⑩",null,null,"新規（被保険者の取得）"]
[null,null,null,null,"被扶養者に\nなった日",null,null,null,null,null,null,null,null,null,"職 業",null,null,"パート",null,null,"高・大学生(",null,null,null,"年生)","収入\n(年収)",null,null,null,null,null,null,null,"理 由",null,null,"婚姻",null,null,"出生",null,null,"収入減"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年金受給者",null,null,"その他(",null,null,null,")",null,null,null,null,null,null,null,"円",null,null,null,"離職",null,null,"その他（",null,null,null,")"]
[null,"非該当",null,null,"⑪",null,null,null,null,null,null,null,null,null,"⑫",null,null,"死亡","(令和",null,"年",null,"月",null,"日)","⑬",null,null,null,null,null,null,null,"⑭",null,null,null,null,null,"発行が必要"]
[null,null,null,null,"被扶養者で\nなくなった日",null,null,null,null,null,null,null,null,null,"理 由",null,null,"就職",null,null,"収入増",null,null,"離婚",null,"備 考",null,null,null,null,null,null,null,"資格確認書\n発行要否"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達 ",null,null,"その他(",null,null,null,")"]
[]
["被扶養者欄４","①",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,null,null,"回収区分","添付\n\n返不能\n\n滅失"]
[null,"(フリガナ)\n\n氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",null,null,null,null,"⑤",null,null,null,null,null,"⑥",null,null,"同居","〒"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"続 柄",null,null,null,null,null,"住 所"]
[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,"別居"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ﾌﾟﾙﾀﾞｳﾝ)"]
[null,"該　当",null,null,"⑦",null,null,null,null,null,null,null,null,null,"⑧",null,null,"無職",null,null,"小・中学生以下",null,null,null,null,"⑨",null,null,null,null,null,null,null,"⑩",null,null,"新規（被保険者の取得）"]
[null,null,null,null,"被扶養者に\nなった日",null,null,null,null,null,null,null,null,null,"職 業",null,null,"パート",null,null,"高・大学生(",null,null,null,"年生)","収入\n(年収)",null,null,null,null,null,null,null,"理 由",null,null,"婚姻",null,null,"出生",null,null,"収入減"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年金受給者",null,null,"その他(",null,null,null,")",null,null,null,null,null,null,null,"円",null,null,null,"離職",null,null,"その他（",null,null,null,")"]
[null,"非該当",null,null,"⑪",null,null,null,null,null,null,null,null,null,"⑫",null,null,"死亡","(令和",null,"年",null,"月",null,"日)","⑬",null,null,null,null,null,null,null,"⑭",null,null,null,null,null,"発行が必要"]
[null,null,null,null,"被扶養者で\nなくなった日",null,null,null,null,null,null,null,null,null,"理 由",null,null,"就職",null,null,"収入増",null,null,"離婚",null,"備 考",null,null,null,null,null,null,null,"資格確認書\n発行要否"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達 ",null,null,"その他(",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,"東京金属事業健康保険組合"]
["⑮扶養に関する申立書（添付書類の内容について補足する事項がある場合に記入してください）",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,"受付印"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"申立の事実に相違ありません。 氏名"]
["2025-04-01"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"裏　面"]
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[null,null,null,null,"健康保険　被扶養者（異動）決定通知書"]
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[]
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["提出者記入欄",null,null,null,"　届書記入の個人番号に誤りがないことを確認しました。"]
[null,"事業所\n所在地",null,null,null,"〒",{"$f":"IF(G6=\"\",\"\",G6)","v":""},"","","",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険の記号"]
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[null,"事業所\n名　称",null,null,null,{"$f":"IF(F9=\"\",\"\",F9)","v":""},"","","","","","","","","","","","","","","","","",null,{"$f":"IF(Y9=\"\",\"\",Y9)","v":""},"","","","","",""]
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[null,"事業主\n氏　名",null,null,"　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　\n　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",{"$f":"IF(F11=\"\",\"\",F11)","v":""},"","","","","","","","","","","","","","","","","",null,"社会保険労務士記載欄"]
[null,null,null,null,null,{"$f":"IF(F12=\"\",\"\",F12)","v":""},"","","","","","","","","","","","","","","","","","　","　　氏　　名　　等"]
[null,"電話番号",null,null,null,{"$f":"IF(F13=\"\",\"\",F13)","v":""},"","","","","","","","","","","","","","","","","",null,{"$f":"IF(Y13=\"\",\"\",Y13)","v":""},"","","","","","","","","","","","","","","","",""]
[null,null,null,null,null,{"$f":"IF(F14=\"\",\"\",F14)","v":""},"","","","","","","","","","","","","","","","","",null,{"$f":"IF(Y14=\"\",\"\",Y14)","v":""},"","","","","","","","","","","","","","","","",""]
[]
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[null,"被保険者等番号",null,null,{"$f":"IF(E17=\"\",\"\",E17)","v":""},"","","","","(ﾌﾘｶﾞﾅ)",null,"(氏)",{"$f":"IF(M17=\"\",\"\",M17)","v":""},"","","","","","","(名)",{"$f":"IF(U17=\"\",\"\",U17)","v":""},"","","","","","","生年\n月日",null,null,{"$f":"IF(AE17=\"\",\"\",AE17)","v":""},"","","","","","","","","性別",null,null,{"$f":"IF(AQ17=\"\",\"\",AQ17)","v":""},""]
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[null,null,null,null,{"$f":"IF(E22=\"\",\"\",E22)","v":""},"","","","","","","","",null,null,null,"千円",null,null,null,null,null,null,null,{"$f":"IF(Y22=\"\",\"\",Y22)","v":""},"","","","","","","","","","","","","","","","","",""]
[null,"被扶養者でない配偶者が",null,null,null,null,null,null,true,"いる",null,"1．いるの場合、年収見込をご記入ください",null,null,null,null,null,null,null,null,null,{"$f":"IF(V23=\"\",\"\",V23)","v":""},"","","","",null,"※配偶者以外の同居の家族を扶養に追加する場合にご記入ください。"]
[null,null,null,null,null,null,null,null,true,"いない",null,"配偶者の年収見込額",null,null,null,null,null,null,null,null,null,{"$f":"IF(V24=\"\",\"\",V24)","v":""},"","","","","円"," 配偶者の追加には、収入確認書類が必要になる場合があります。(副本裏面参照)"]
["※被扶養者の「該当」と「非該当」は同時に提出できません。「該当」、「非該当」はそれぞれ別の用紙で提出してください。"]
["被扶養者になった場合は「該当」、被扶養者でなくなった場合は「非該当」を〇で囲んでください。"]
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[null,"(フリガナ)\n\n氏 名",null,null,null,{"$f":"IF(F28=\"\",\"\",F28)","v":""},"","","","",null,{"$f":"IF(L28=\"\",\"\",L28)","v":""},"","","","","生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号",null,null,"************"]
[null,null,null,null,"(氏)",{"$f":"IF(F29=\"\",\"\",F29)","v":""},"","","","","(名)",{"$f":"IF(L29=\"\",\"\",L29)","v":""},"","","",""]
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[null,null,null,null,null,{"$f":"IF(F31=\"\",\"\",F31)","v":""},"","","","",null,{"$f":"IF(L31=\"\",\"\",L31)","v":""},"","","","","性 別",null,{"$f":"IF(S31=\"\",\"\",S31)","v":""},"","","続 柄",null,{"$f":"IF(X31=\"\",\"\",X31)","v":""},"","","","住 所",null,null,null,{"$f":"IF(AF31=\"\",\"\",AF31)","v":""},"","","","","","","","",""]
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[null,null,null,null,null,{"$f":"IF(F33=\"\",\"\",F33)","v":""},"","","","",null,{"$f":"IF(L33=\"\",\"\",L33)","v":""},"","","","",null,null,{"$f":"IF(S33=\"\",\"\",S33)","v":""},"","",null,null,{"$f":"IF(X33=\"\",\"\",X33)","v":""},"","","",null,null,null,null,{"$f":"IF(AF33=\"\",\"\",AF33)","v":""},"","","","","","","","",""]
[null,"該　当",null,null,"⑦",null,{"$f":"IF(G34=\"\",\"\",G34)","v":""},"","","","","","","","⑧",null,true,"無職",null,true,"小・中学生以下",null,null,null,null,"⑨",null,{"$f":"IF(AB34=\"\",\"\",AB34)","v":""},"","","","","","⑩",null,true,"新規（被保険者の取得）"]
[null,null,null,null,"被扶養者に\nなった日",null,{"$f":"IF(G35=\"\",\"\",G35)","v":""},"","","","","","","","職 業",null,true,"パート",null,true,"高・大学生(",null,null,{"$f":"IF(X35=\"\",\"\",X35)","v":""},"年生)","収入\n(年収)",null,{"$f":"IF(AB35=\"\",\"\",AB35)","v":""},"","","","","","理由",null,true,"婚姻",null,true,"出生",null,true,"収入減"]
[null,null,null,null,null,null,{"$f":"IF(G36=\"\",\"\",G36)","v":""},"","","","","","","",null,null,true,"年金受給者",null,true,"その他(",null,{"$f":"IF(W36=\"\",\"\",W36)","v":""},"",")",null,null,null,null,null,null,null,"円",null,null,true,"離職",null,true,"その他（",null,{"$f":"IF(AP36=\"\",\"\",AP36)","v":""},"",")"]
[null,"非該当",null,null,"⑪",null,{"$f":"IF(G37=\"\",\"\",G37)","v":""},"","","","","","","","⑫",null,true,"死亡","(令和",{"$f":"IF(T37=\"\",\"\",T37)","v":""},"年",{"$f":"IF(V37=\"\",\"\",V37)","v":""},"月",{"$f":"IF(X37=\"\",\"\",X37)","v":""},"日)","⑬",null,{"$f":"IF(AB37=\"\",\"\",AB37)","v":""},"","","","","","⑭",null,null,null,null,null,"発行が必要"]
[null,null,null,null,"被扶養者で\nなくなった日",null,{"$f":"IF(G38=\"\",\"\",G38)","v":""},"","","","","","","","理 由",null,true,"就職",null,true,"収入増",null,true,"離婚",null,"備 考",null,{"$f":"IF(AB38=\"\",\"\",AB38)","v":""},"","","","","","資格確認書\n発行要否"]
[null,null,null,null,null,null,{"$f":"IF(G39=\"\",\"\",G39)","v":""},"","","","","","","",null,null,true,"75歳到達 ",null,true,"その他(",null,{"$f":"IF(W39=\"\",\"\",W39)","v":""},"",")",null,null,{"$f":"IF(AB39=\"\",\"\",AB39)","v":""},"","","","",""]
[]
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[null,"(フリガナ)\n\n氏 名",null,null,null,{"$f":"IF(F42=\"\",\"\",F42)","v":""},"","","","",null,{"$f":"IF(L42=\"\",\"\",L42)","v":""},"","","","","生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号",null,null,"************"]
[null,null,null,null,"(氏)",{"$f":"IF(F43=\"\",\"\",F43)","v":""},"","","","","(名)",{"$f":"IF(L43=\"\",\"\",L43)","v":""},"","","",""]
[null,null,null,null,null,{"$f":"IF(F44=\"\",\"\",F44)","v":""},"","","","",null,{"$f":"IF(L44=\"\",\"\",L44)","v":""},"","","","","④",null,{"$f":"IF(S44=\"\",\"\",S44)","v":""},"","","⑤",null,{"$f":"IF(X44=\"\",\"\",X44)","v":""},"","","","⑥",null,true,"同居","〒",{"$f":"IF(AG44=\"\",\"\",AG44)","v":""},"","",""]
[null,null,null,null,null,{"$f":"IF(F45=\"\",\"\",F45)","v":""},"","","","",null,{"$f":"IF(L45=\"\",\"\",L45)","v":""},"","","","","性 別",null,{"$f":"IF(S45=\"\",\"\",S45)","v":""},"","","続 柄",null,{"$f":"IF(X45=\"\",\"\",X45)","v":""},"","","","住 所",null,null,null,{"$f":"IF(AF45=\"\",\"\",AF45)","v":""},"","","","","","","","",""]
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[]
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[]
["被扶養者欄４","①",null,null,null,{"$f":"IF(F69=\"\",\"\",F69)","v":""},"","","","",null,{"$f":"IF(L69=\"\",\"\",L69)","v":""},"","","","","②",null,{"$f":"IF(S69=\"\",\"\",S69)","v":""},null,null,null,null,null,null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,null,null,"回収区分","添付\n\n返不能\n\n滅失"]
[null,"(フリガナ)\n\n氏 名",null,null,null,{"$f":"IF(F70=\"\",\"\",F70)","v":""},"","","","",null,{"$f":"IF(L70=\"\",\"\",L70)","v":""},"","","","","生年\n月日",null,null,null,null,null,null,null,null,null,null,"個人\n番号",null,null,"************"]
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[null,null,null,null,null,{"$f":"IF(F75=\"\",\"\",F75)","v":""},"","","","",null,{"$f":"IF(L75=\"\",\"\",L75)","v":""},"","","","",null,null,{"$f":"IF(S75=\"\",\"\",S75)","v":""},"","",null,null,{"$f":"IF(X75=\"\",\"\",X75)","v":""},"","","",null,null,null,null,{"$f":"IF(AF75=\"\",\"\",AF75)","v":""},"","","","","","","","",""]
[null,"該　当",null,null,"⑦",null,{"$f":"IF(G76=\"\",\"\",G76)","v":""},"","","","","","","","⑧",null,true,"無職",null,true,"小・中学生以下",null,null,null,null,"⑨",null,{"$f":"IF(AB76=\"\",\"\",AB76)","v":""},"","","","","","⑩",null,true,"新規（被保険者の取得）"]
[null,null,null,null,"被扶養者に\nなった日",null,{"$f":"IF(G77=\"\",\"\",G77)","v":""},"","","","","","","","職 業",null,true,"パート",null,true,"高・大学生(",null,null,{"$f":"IF(X77=\"\",\"\",X77)","v":""},"年生)","収入\n(年収)",null,{"$f":"IF(AB77=\"\",\"\",AB77)","v":""},"","","","","","理由",null,true,"婚姻",null,true,"出生",null,true,"収入減"]
[null,null,null,null,null,null,{"$f":"IF(G78=\"\",\"\",G78)","v":""},"","","","","","","",null,null,true,"年金受給者",null,true,"その他(",null,{"$f":"IF(W78=\"\",\"\",W78)","v":""},"",")",null,null,null,null,null,null,null,"円",null,null,true,"離職",null,true,"その他（",null,{"$f":"IF(AP78=\"\",\"\",AP78)","v":""},"",")"]
[null,"非該当",null,null,"⑪",null,{"$f":"IF(G79=\"\",\"\",G79)","v":""},"","","","","","","","⑫",null,true,"死亡","(令和",{"$f":"IF(T79=\"\",\"\",T79)","v":""},"年",{"$f":"IF(V79=\"\",\"\",V79)","v":""},"月",{"$f":"IF(X79=\"\",\"\",X79)","v":""},"日)","⑬",null,{"$f":"IF(AB79=\"\",\"\",AB79)","v":""},"","","","","","⑭",null,null,null,null,null,"発行が必要"]
[null,null,null,null,"被扶養者で\nなくなった日",null,{"$f":"IF(G80=\"\",\"\",G80)","v":""},"","","","","","","","理 由",null,true,"就職",null,true,"収入増",null,true,"離婚",null,"備 考",null,{"$f":"IF(AB80=\"\",\"\",AB80)","v":""},"","","","","","資格確認書\n発行要否"]
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[]
[null,"被保険者　様"]
[]
[]
[null,null,null,null,null,null,null,null,"上記のとおり決定しました。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"令和　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"東京金属事業健康保険組合理事長"]
[]
[]
[null,"この通知は速やかに被保険者に交付してください。"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"　この処分に不服があるときは、処分があったことを知った日の翌日から起算"]
[null,null,null,null,"して３か月以内に文書又は口頭で社会保険審査官（地方厚生（支）局内）に対"]
[null,null,null,null,"して審査請求をすることができます。また、審査請求の決定に不服があるとき"]
[null,null,null,null,"は、再審査請求又は処分の取消しの訴えを提起することができます。"]
[null,null,null,null,"　再審査請求は、審査官の決定書の謄本が送付された日の翌日から起算して２"]
[null,null,null,null,"か月以内に文書又は口頭で社会保険審査会（厚生労働省内）に対して行うこと"]
[null,null,null,null,"ができ、処分の取消しの訴えは、審査請求の決定があったことを知った日から"]
[null,null,null,null,"６か月以内（再審査請求があったときは、その裁決があったことを知った日か"]
[null,null,null,null,"ら６か月以内）健康保険組合を被告として提起することができます。（ただし、"]
[null,null,null,null,"原則として、決定又は裁決の日から１年を経過したときは、提起することがで"]
[null,null,null,null,"きなくなります。）なお、審査請求があった日から２か月を経過しても決定が"]
[null,null,null,null,"ないときや、処分の執行等による著しい損害を避けるため緊急の必要があると"]
[null,null,null,null,"き、その他正当な理由があるときは、審査請求の決定を経なくても再審査請求"]
[null,null,null,null,"又は処分の取消しの訴えを提起することができます。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"お問い合わせ先：東京金属事業健康保険組合"]
[null,null,null,null,"<本 　　　部>　電話　０３－３８６６－２８６５（業務部　適用課）"]
[null,null,null,null,"<多 摩 支 部>　電話　０３－５８３９－２４４１（業務課）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["副",null,null,null,"健康保険　被扶養者（異動）届"]
[]
[]
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["提出者記入欄",null,null,null,"　届書記入の個人番号に誤りがないことを確認しました。"]
[null,"事業所\n所在地",null,null,null,"〒",{"$f":"IF(G6=\"\",\"\",G6)","v":""},"","","",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険の記号"]
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[null,"事業所\n名　称",null,null,null,{"$f":"IF(F9=\"\",\"\",F9)","v":""},"","","","","","","","","","","","","","","","","",null,{"$f":"IF(Y9=\"\",\"\",Y9)","v":""},"","","","","",""]
[null,null,null,null,null,{"$f":"IF(F10=\"\",\"\",F10)","v":""},"","","","","","","","","","","","","","","","",""]
[null,"事業主\n氏　名",null,null,"　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　\n　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",{"$f":"IF(F11=\"\",\"\",F11)","v":""},"","","","","","","","","","","","","","","","","",null,"社会保険労務士記載欄"]
[null,null,null,null,null,{"$f":"IF(F12=\"\",\"\",F12)","v":""},"","","","","","","","","","","","","","","","","","　","　　氏　　名　　等"]
[null,"電話番号",null,null,null,{"$f":"IF(F13=\"\",\"\",F13)","v":""},"","","","","","","","","","","","","","","","","",null,{"$f":"IF(Y13=\"\",\"\",Y13)","v":""},"","","","","","","","","","","","","","","","",""]
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[]
["被保険者欄","①",null,null,{"$f":"IF(E16=\"\",\"\",E16)","v":""},"","","","","②",null,null,{"$f":"IF(M16=\"\",\"\",M16)","v":""},"","","","","","",null,{"$f":"IF(U16=\"\",\"\",U16)","v":""},"","","","","","","③",null,null,{"$f":"IF(AE16=\"\",\"\",AE16)","v":""},"","","","","","","","","④",null,null,{"$f":"IF(AQ16=\"\",\"\",AQ16)","v":""},""]
[null,"被保険者等番号",null,null,{"$f":"IF(E17=\"\",\"\",E17)","v":""},"","","","","(ﾌﾘｶﾞﾅ)",null,"(氏)",{"$f":"IF(M17=\"\",\"\",M17)","v":""},"","","","","","","(名)",{"$f":"IF(U17=\"\",\"\",U17)","v":""},"","","","","","","生年\n月日",null,null,{"$f":"IF(AE17=\"\",\"\",AE17)","v":""},"","","","","","","","","性別",null,null,{"$f":"IF(AQ17=\"\",\"\",AQ17)","v":""},""]
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[null,"⑤",null,null,{"$f":"IF(E20=\"\",\"\",E20)","v":""},"","","","","","","","","⑥",null,null,{"$f":"IF(Q20=\"\",\"\",Q20)","v":""},"","","","⑦",null,null,"〒",{"$f":"IF(Y20=\"\",\"\",Y20)","v":""},"","",""]
[null,"取　得\n年月日",null,null,{"$f":"IF(E21=\"\",\"\",E21)","v":""},"","","","","","","","","標準報酬\n月　　額",null,null,{"$f":"IF(Q21=\"\",\"\",Q21)","v":""},"","","","住 所",null,null,null,{"$f":"IF(Y21=\"\",\"\",Y21)","v":""},"","","","","","","","","","","","","","","","","",""]
[null,null,null,null,{"$f":"IF(E22=\"\",\"\",E22)","v":""},"","","","","","","","",null,null,null,"千円",null,null,null,null,null,null,null,{"$f":"IF(Y22=\"\",\"\",Y22)","v":""},"","","","","","","","","","","","","","","","","",""]
[null,"被扶養者でない配偶者が",null,null,null,null,null,null,true,"いる",null,"1．いるの場合、年収見込をご記入ください",null,null,null,null,null,null,null,null,null,{"$f":"IF(V23=\"\",\"\",V23)","v":""},"","","","",null,"※配偶者以外の同居の家族を扶養に追加する場合にご記入ください。"]
[null,null,null,null,null,null,null,null,true,"いない",null,"配偶者の年収見込額",null,null,null,null,null,null,null,null,null,{"$f":"IF(V24=\"\",\"\",V24)","v":""},"","","","","円"," 配偶者の追加には、収入確認書類が必要になる場合があります。(副本裏面参照)"]
["※被扶養者の「該当」と「非該当」は同時に提出できません。「該当」、「非該当」はそれぞれ別の用紙で提出してください。"]
["被扶養者になった場合は「該当」、被扶養者でなくなった場合は「非該当」を〇で囲んでください。"]
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[null,null,null,null,null,null,null,null,"上記のとおり決定しました。"]
[]
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[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"令和　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"東京金属事業健康保険組合理事長"]
[]
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[]
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[null,"この届出書は、「被扶養者になった場合」、「被扶養者でなくなった場合」、「被扶養者情報を変更する場合」にご提出いただくものです。"]
[]
[null,"記入方法"]
[null,"＜被保険者欄＞"]
[null,null,"①被保険者等番号",null,null,null,null,null,null,"：　被保険者等番号を入力してください。"]
[null,null,"②氏名",null,null,null,null,null,null,"：　氏名を入力し、フリガナはカタカナで正確に入力してください。（ローマ字は不可）"]
[null,null,"③生年月日",null,null,null,null,null,null,"：　生年月日は右図のように入力してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",null,"男",null,null,"③",null,"1988-05-10"]
[null,null,"④性別",null,null,null,null,null,null,"：　性別はプルダウンリストから選択してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"生年\n月日"]
[null,null,"⑤取得年月日",null,null,null,null,null,null,"：　被保険者が健康保険に加入した日付を入力してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ﾌﾟﾙﾀﾞｳﾝ)"]
[null,null,"⑥標準報酬月額",null,null,null,null,null,null,"：　被保険者の標準報酬月額を入力してください。"]
[null,null,"⑦住所",null,null,null,null,null,null,"：　住民票の住所を入力してください。住民票の住所と居所が異なる場合は、別途「居所登録届」をご提出ください。"]
[]
[null,null,"※被扶養者でない配偶者がいる場合で、配偶者以外の家族を扶養とするときは、「いる」にチェックを入れ、配偶者の年収見込額を入力してください。"]
[null,null,"　配偶者がいない場合は、「いない」にチェックしてください。"]
[]
[null,"＜被扶養者欄＞"]
[null,null,"①氏名",null,null,null,null,null,null,"：　氏名を入力し、フリガナはカタカナで正確に入力してください。（ローマ字は不可）"]
[null,null,"②生年月日",null,null,null,null,null,null,"：　生年月日は右上図のように入力してください。"]
[null,null,"③個人番号",null,null,null,null,null,null,"：　必ず本人確認を行ったうえで、個人番号（１２桁）を入力してください。基礎年金番号は入力しないでください。"]
[null,null,null,null,null,null,null,null,null,"　　なお、扶養削除の届出の場合には記入しないでください。"]
[null,null,"④性別",null,null,null,null,null,null,"：　性別はプルダウンリストから選択してください。"]
[null,null,"⑤続柄",null,null,null,null,null,null,"：　被保険者との続柄を「夫」、「妻」、「父」、「母」、「祖父」、「祖母」、子供の場合は「子」ではなく「長男」、「長女」などと入力してください。"]
[null,null,"⑥住所",null,null,null,null,null,null,"：　同居・別居の該当する方にチェックを入れてください。なお、同居の場合は住所の入力は不要です。"]
[null,null,"⑦被扶養者になった日",null,null,null,null,null,null,"：　被保険者の健康保険加入と同時に提出する場合は被保険者の「⑤取得年月日」と同日、それ以外の場合は出生年月日等の実際に被扶養者になった日を"]
[null,null,null,null,null,null,null,null,null,"　　入力してください。　"]
[null,null,"⑧職業",null,null,null,null,null,null,"：　現在の職業にチェックしてください。"]
[null,null,"⑨年収",null,null,null,null,null,null,"：　今後１年間の年間収入見込額を入力してください。収入には、非課税対象のもの(障害・遺族年金、失業給付等)も含みます。"]
[null,null,"⑩理由",null,null,null,null,null,null,"：　被扶養者となった理由にチェックしてください。"]
[null,null,"⑪被扶養者でなくなった日",null,null,null,null,null,null,"：　死亡による場合は死亡の翌日を、それ以外の場合は非該当になった当日の日付を入力してください。"]
[null,null,"⑫理由",null,null,null,null,null,null,"：　被扶養者でなくなった理由にチェックしてください。死亡の場合は亡くなった日付を入力してください。"]
[null,null,"⑭資格確認書発行要否",null,null,null,null,null,null,"：　資格確認書の発行が必要な場合（※）は、「□発行が必要」にチェックを入れてください。"]
[null,null,null,null,null,null,null,null,null,"※以下に該当する場合に限ります。"]
[null,null,null,null,null,null,null,null,null,"　・マイナンバーカードを取得していない方、マイナンバーカードの返納者"]
[null,null,null,null,null,null,null,null,null,"　・マイナンバーカードを保有しているが健康保険証利用登録を行っていない方、利用登録解除した方又は解除を申請した方"]
[null,null,null,null,null,null,null,null,null,"　・マイナンバーカードの電子証明書の有効期限切れの方"]
[null,null,"⑮扶養に関する申立書",null,null,null,null,null,null,"：　被扶養者情報に特筆すべきことがある場合その内容等を入力し署名してください。"]
[]
[null,"添付書類"]
[]
[null,"原則として１６歳以上の方を扶養認定申請する場合は、以下の添付書類が必要となります。"]
[null,"・所得に関する証明書類"]
[null,"・生計維持に関する証明書類"]
[null,"・身分関係の確認出来る証明書類　　　　など"]
[]
[null,"※具体的な添付書類については、当組合ホームページをご覧ください。"]
[null,"「TOPページ」　→　「健康保険の給付・資格確認書等のことなど」　　→　「家族の加入について」　→　「手続き」　→　「家族を加入させるとき」　→　「認定のための添付書類」"]
[]
[]
[]
[]
[]
[]
[null,"◎被扶養者（異動）決定通知書について"]
[]
[null,"　令和５年１２月２７日付で厚生労働省保険局保険課から発出された事務連絡において、被扶養者（異動）届の提出により健康保険組合が"]
[null,"扶養認定・削除を行った際、被保険者あてに「被扶養者（異動）決定通知書」を発出することが義務付けられました。"]
[null," 「被扶養者（異動）決定通知書」、「健康保険　被扶養者（異動）届　副」を当組合より発送いたしますので当該の被保険者様に「被扶養者"]
[null,"（異動）決定通知書」をお渡しください。また「健康保険　被扶養者（異動）届　副」は事業主控えとして保管してください。"]

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