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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 主 （ 事 業 主 代 理 人 ） 記 入 箇 所"]
["取扱注意",null,null,null,null,null,null,"　　　健康保険被扶養者異動届（扶養するとき）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記の通り被保険者から被扶養者の届出がありましたので提出します。"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　令和　　　　　年　　　　　月　　　　　日　　提出"]
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["健 康 保 険 組 合",null,null,null,null,null,null,null,null,null,null,null,null,"健保受付",null,null,null,null,null,"健　康　保　険　組　合　　記　入　欄"]
["　　　　長",null,null,null,"　　　　長",null,null,null,"担当者"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異動年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"補\n記\n事\n項",null,null,null,null,null,null,null,null,null,null,null,"事業所所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｈ\n\nＲ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所名称"]
[]
[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,"事業主氏名"]
[]
["関西電力健康保険組合　常務理事　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円","×",null,null,"＝",null,null,null,"万円",null,"/2＝",null,null,null,null,null,null,"電話番号"]
[]
[]
["※１（押印省略）自署の場合または確認欄の要件に該当し☑を入れた場合は、押印を省略できます。",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,"事業主確認欄（以下の内容に該当する場合は、事業主にて確認し☑願います）"]
["この届出については、①または②の要件を満たしたものです。\n①申請者本人（被保険者）が作成したものです。②記載内容について誤りがないか申請者本人が確認しています。",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,"確認欄","□",null,null,null,null,"　被保険者との続柄に関する証明書類が省略されている者については、続柄を確認しています。（内縁関係は省略不可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"確認欄","□"]
[]
["被\n\n保\n\n険\n\n者\n\n記\n\n入\n\n欄","被 保 険 者 番 号",null,null,null,null,null,null,"被保険者　氏名",null,null,null,null,null,null,null,null,null,"被保険者　生年月日",null,null,null,null,null,"所　属（※任意継続被保険者は記入不要）",null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　住　民　票　住　所"]
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[null,"被　扶　養　者　名",null,null,null,null,null,null,null,null,null,"性\n別","続柄\n例)長男",null,"生 年 月 日",null,null,null,null,null,null,"　職業･学年　等\n例)ﾊﾟｰﾄ、高校1年生、無職",null,null,null,null,"収　入（※２）",null,null,null,null,null,null,"申　　請　　事　　由\n\n※下記申請事由の区分より選択下さい。",null,null,null,null,null,null,null,null,null,null," 扶養要件を満たした日",null,null,null,null,null,null,"同居・別居\n※別居の場合は別居理由\n　を詳しく記入下さい。\n　例）単身赴任・就学"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,"被扶養者　住　所"]
[null,"フ　　リ　　ガ　　ナ",null,null,null,null,null,null,null,null,null,"個人番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,"年　額"]
[null,"姓",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,null,null,null,"号","年",null,"月",null,"日"]
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[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D35","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",{"$f":"申請者入力!D36","v":0},"-",{"$f":"申請者入力!E36","v":0},{"$f":"申請者入力!G36","v":0},"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,{"$f":"IF(申請者入力!E40=\"\",\"\",+申請者入力!E40)","v":""},null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D37","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D29,1,1)","v":""},{"$f":"MID(申請者入力!D29,2,1)","v":""},{"$f":"MID(申請者入力!D29,3,1)","v":""},{"$f":"MID(申請者入力!D29,4,1)","v":""},{"$f":"MID(申請者入力!D29,5,1)","v":""},{"$f":"MID(申請者入力!D29,6,1)","v":""},{"$f":"MID(申請者入力!D29,7,1)","v":""},{"$f":"MID(申請者入力!D29,8,1)","v":""},{"$f":"MID(申請者入力!D29,9,1)","v":""},{"$f":"MID(申請者入力!D29,10,1)","v":""},{"$f":"MID(申請者入力!D29,11,1)","v":""},{"$f":"MID(申請者入力!D29,12,1)","v":""},"その他\n(傷病手当、株配当等)",null,{"$f":"IF(申請者入力!E41=\"\",\"\",+申請者入力!E41)","v":""},null,null,null,"円"]
[null,{"$f":"+申請者入力!D49","v":0},null,null,null,null,{"$f":"+申請者入力!E49","v":0},null,null,null,null,{"$f":"+申請者入力!D51","v":0},{"$f":"+申請者入力!D52","v":0},null,{"$f":"+申請者入力!D53","v":"00:00:00"},null,null,null,null,null,null,{"$f":"+申請者入力!D54","v":0},null,null,null,null,"給与",null,{"$f":"IF(申請者入力!E59=\"\",\"\",+申請者入力!E59)","v":""},null,null,null,"円","区分",null,null,null,null,null,null,null,null,null,null,{"$f":"IF(申請者入力!D$65=\"\",\"\",IF(申請者入力!D$65>=43586,\"R\",TEXT(申請者入力!D$65,\"g\")))","v":""},{"$f":"IF(申請者入力!D$65=\"\",\"\",IF(AS38=\"R\",\"0\",MID(TEXT(申請者入力!D$65,\"ee\"),1,1)))","v":""},{"$f":"IF(申請者入力!D$65=\"\",\"\",MID(TEXT(申請者入力!D$65,\"ee\"),2,1))","v":""},{"$f":"IF(申請者入力!D$65=\"\",\"\",MID(TEXT(申請者入力!D$65,\"mm\"),1,1))","v":""},{"$f":"IF(申請者入力!D$65=\"\",\"\",MID(TEXT(申請者入力!D$65,\"mm\"),2,1))","v":""},{"$f":"IF(申請者入力!D$65=\"\",\"\",MID(TEXT(申請者入力!D$65,\"dd\"),1,1))","v":""},{"$f":"IF(申請者入力!D$65=\"\",\"\",MID(TEXT(申請者入力!D$65,\"dd\"),2,1))","v":""},"同・別","（別居理由）"]
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[null,{"$f":"+申請者入力!D48","v":0},null,null,null,null,{"$f":"+申請者入力!E48","v":0},null,null,null,null,"住民票住所","〒",{"$f":"申請者入力!D55","v":0},"-",{"$f":"申請者入力!E55","v":0},{"$f":"申請者入力!G41","v":0},"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,{"$f":"IF(申請者入力!E60=\"\",\"\",+申請者入力!E60)","v":""},null,null,null,"円",{"$f":"申請者入力!D63","v":"00:00:00"}]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D56","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",{"$f":"申請者入力!D57","v":0},"-",{"$f":"申請者入力!E57","v":0},{"$f":"申請者入力!G43","v":0},"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,{"$f":"IF(申請者入力!E61=\"\",\"\",+申請者入力!E61)","v":""},null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"申請者入力!D58","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(+申請者入力!D43=\"\",\"\",申請者入力!D43)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D50,1,1)","v":""},{"$f":"MID(申請者入力!D50,2,1)","v":""},{"$f":"MID(申請者入力!D50,3,1)","v":""},{"$f":"MID(申請者入力!D50,4,1)","v":""},{"$f":"MID(申請者入力!D50,5,1)","v":""},{"$f":"MID(申請者入力!D50,6,1)","v":""},{"$f":"MID(申請者入力!D50,7,1)","v":""},{"$f":"MID(申請者入力!D50,8,1)","v":""},{"$f":"MID(申請者入力!D50,9,1)","v":""},{"$f":"MID(申請者入力!D50,10,1)","v":""},{"$f":"MID(申請者入力!D50,11,1)","v":""},{"$f":"MID(申請者入力!D50,12,1)","v":""},"その他\n(傷病手当、株配当等)",null,{"$f":"IF(申請者入力!E62=\"\",\"\",申請者入力!E62)","v":""},null,null,null,"円"]
[null,"遡及理由（届出遅延理由）申立書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"共同扶養する他保険や他組合の被保険者の年収確認"]
[]
[]
[null,"遡って認定すべき理由が有る場合は、下記へ記入（チェック）して下さい。\n※原則は健康保険組合受付日が認定日です。必ず遡及できるとは限りません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"上記被扶養者を認定するにあたって、共同で生活を支えている方（共同扶養者）※が存在する場合、申請者（被保険者）と共同で\n生活を支えている方（共同扶養者）と双方の収入を確認しますので、「共同扶養における収入額確認表」と必要書類を添付して\nください。\n※該当する方\n　被扶養者になっていない配偶者・届出しようとしている被扶養者と同一世帯である他健保等の被保険者（父母、兄弟、姉妹等）"]
[]
[]
[]
[]
[null,"□","申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）"]
[null,"□","その他（下記余白へ記入して下さい。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入にあたっての留意点（ご一読下さい）"]
[null,{"$f":"+[1]申請者入力!D16","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","届出内容に誤りや虚偽の内容があった場合、被扶養者の認定そのものを取り消すことがあります。\nその間に使用された医療費は全額お返しいただきます。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　※署名は直筆で記入願います。\n氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","個人番号については、健康保険届出事務に関して利用するものです。"]
[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,"補足事項"]
[null,null,"上記の事実に相違ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※２：収入は届出時点から向こう１年間の見込み額を記入してください。"]
[]
[null,"ご記入いただいた個人情報は、当該の利用目的以外には使用いたしません。",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,null,null,null,null,null,null,null,null,null,null,null,"令和６年２月更新"]

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["入力シート"]
[null,null,"１．下記項目（黄色）に入力してください。\n２．入力後、右のボタンをクリックし、届出内容を確認後印刷し、\n　　捺印（用紙中段付近と左下の２箇所）の上、担当箇所へご提出ください。"]
[]
["１．被保険者・共同扶養者情報入力"]
[null,"会社名\n(選択してください)",null,"501．関西電力株式会社",null,"リスト選択",null,{"$f":"IF(VLOOKUP(D5,リスト!$B$75:$F$111,5,0)=1,\"\",1)","v":1}]
[null,"所　　属",null,null,null,"入力"]
[null,null,"住民票住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）",null,null,"入力"]
[null,null,"住民票住所\n",null,null,"入力"]
[null,null,"居所住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）",null,null,"入力"]
[null,null,"居所住所\n※住民票住所と同じ場合は同上とご記入下さい\n",null,null,"入力"]
[]
[null,"被保険者","被保険者番号",null,null,"入力"]
[null,null,"氏名",null,null,"入力"]
[null,null,"生年月日",null,"入力例：「1970/3/3」","入力"]
[null,null,"遡及理由申立",null,"←その他理由を選択される場合のみ変更","リスト"]
[null,null,"その他の理由",null,{"$f":"IF(D15=\"その他（下記余白へ記入して下さい。）\",\"←理由を入力してください。\",\"←入力不要\")","v":"←入力不要"}]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["2．被扶養者情報入力"]
[null,"被扶養者１","被扶養者氏名（姓・名）",null,null,"入力"]
[null,null,"被扶養者カナ（セイ・メイ）",null,null,"入力"]
[null,null,"個人番号",null,"入力例：１２桁「000123456789」","入力"]
[null,null,"性別",null,"入力例：「男」、「女」","入力"]
[null,null,"続柄",null,"入力例：「長男」、「長女」等","入力"]
[null,null,"生年月日",null,"入力例：「2018/5/1」","入力"]
[null,null,"職業",null,"入力例：「ﾊﾟｰﾄ」、「高校1年生」、\n「無職」等","入力"]
[null,null,"住民票住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"住民票住所\n※被保険者の住民票住所と別の場合に入力"]
[null,null,"居所住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"居所住所\n※被保険者の居所住所と別の場合に入力"]
[null,null,"収入（年額）\n※円単位で入力してください。\n※「O」円の場合は、「０」と入力","給与",null,"入力"]
[null,null,null,"年金",null,"入力"]
[null,null,null,"事業",null,"入力"]
[null,null,null,"その他\n(傷病手当金・株式配当等）",null,"入力"]
[null,null,"申請事由",null,null,"リスト選択","→"]
[null,null,null,null,{"$f":"IF($D$42=\"Ｈ\",\"←具体的理由を入力してください\",\"←入力不要\")","v":"←入力不要"}]
[null,null,"扶養要件を満たした日",null,"入力例：令和元年５月１日の場合→\n７桁2019/5/1」を入力ください。\n（決まっていない場合は、ブランク）","入力"]
[null,null,"同居区分",null,null,"リスト選択"]
[null,null,"別居理由",null,{"$f":"IF($D$45=\"別居\",\"←別居理由を入力してください\",\"←入力不要\")","v":"←入力不要"}]
[]
[null,"被扶養者2","被扶養者氏名（姓・名）",null,null,"入力"]
[null,null,"被扶養者カナ（セイ・メイ）",null,null,"入力"]
[null,null,"個人番号",null,"入力例：１２桁「000123456789」","入力"]
[null,null,"性別",null,"入力例：「男」、「女」","リスト選択"]
[null,null,"続柄",null,"入力例：「長男」、「長女」等","入力"]
[null,null,"生年月日",null,"入力例：「2018/5/1」","入力"]
[null,null,"職業",null,"入力例：「無職」、「アルバイト」等","入力"]
[null,null,"住民票住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"住民票住所\n※被保険者の住民票住所と別の場合に入力"]
[null,null,"居所住所の郵便番号\n例：０１２（左枠）\n　３４５６ （右枠）"]
[null,null,"居所住所\n※被保険者の居所住所と別の場合に入力"]
[null,null,"収入（年額）\n※円単位で入力してください。\n※「O」円の場合は、「０」と入力","給与",null,"入力"]
[null,null,null,"年金",null,"入力"]
[null,null,null,"事業",null,"入力"]
[null,null,null,"その他\n(傷病手当金・株式配当等）",null,"入力"]
[null,null,"申請事由",null,{"$f":"IF(D63=\"\",\"\",VLOOKUP(D63,リスト!$B$32:$D$39,2,0))","v":""},"リスト選択","→"]
[null,null,null,null,{"$f":"IF($D$63=\"Ｈ\",\"←被扶養者１として入力された内容を表示します。\",\"←入力不要\")","v":"←入力不要"}]
[null,null,"扶養要件を満たした日",null,"入力例：令和元年５月１日の場合→\n７桁2019/5/1」を入力ください。\n（決まっていない場合は、ブランク）","入力"]
[null,null,"同居区分",null,null,"リスト選択"]
[null,null,"別居理由",null,{"$f":"IF($D$66=\"別居\",\"←別居理由を入力してください\",\"←入力不要\")","v":"←入力不要"}]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"→"]

{"sheet":"リスト","index":2,"n_rows":111,"n_cols":17,"rows_kept":111,"cut":false,"hidden":true,"merged":[[1,10,1,16]]}
[]
[null,"会社名",null,null,null,null,null,null,null,null,"続柄一覧"]
[null,"001.関西電力株式会社",null,null,null,1,null,null,null,null,"名称","名称","名称","名称","名称","名称","名称"]
[null,"002.○○○",null,null,null,0,null,null,null,null,"夫","長男","長女","孫男","祖父","兄","叔父"]
[null,null,null,null,null,null,null,null,null,null,"妻","二男","二女","孫女","祖母","弟","叔母"]
[null,null,null,null,null,null,null,null,null,null,"内夫","三男","三女","孫配偶者男","曽祖父","義兄","甥"]
[null,"性別１",null,null,null,null,null,null,null,null,"内妻","四男","四女","孫配偶者女","曽祖母","義弟","姪"]
[null,"男",{"$f":"IF(申請者入力!D30=\"男\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,"五男","五女","父","義祖父","姉","伯父"]
[null,"女",{"$f":"IF(申請者入力!D30=\"女\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,"六男","六女","母","義祖母","妹","伯母"]
[null,null,null,null,null,null,null,null,null,null,null,"七男","七女","養父","養祖父","義姉","他親（男）"]
[null,"性別２",null,null,null,null,null,null,null,null,null,"養子","養女","養母","養祖母","義妹","他親（女）"]
[null,"男",{"$f":"IF(申請者入力!D51=\"男\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,"子夫","子養","義父"]
[null,"女",{"$f":"IF(申請者入力!D51=\"女\",\"○\",\"\")","v":""},null,null,null,null,null,null,null,null,null,null,"義母"]
[]
[null,"性別３"]
[null,"男",{"$f":"IF(申請者入力!D72=\"男\",\"○\",\"\")","v":""}]
[null,"女",{"$f":"IF(申請者入力!D72=\"女\",\"○\",\"\")","v":""}]
[]
[]
[]
[null,"申請事由１"]
[null,"Ａ","出生"]
[null,"Ｂ","被保険者資格取得"]
[null,"Ｃ","雇用保険受給終了"]
[null,"Ｄ","退職"]
[null,"Ｅ","結婚"]
[null,"Ｆ","収入減少"]
[null,"Ｇ","別居から同居によるもの"]
[null,"Ｈ","その他（具体的理由を下記に記載）"]
[]
[null,"申請事由２"]
[null,"Ａ","出生"]
[null,"Ｂ","被保険者資格取得"]
[null,"Ｃ","雇用保険受給終了"]
[null,"Ｄ","退職"]
[null,"Ｅ","結婚"]
[null,"Ｆ","収入減少"]
[null,"Ｇ","別居から同居によるもの"]
[null,"Ｈ","その他（扶養者１に記載）"]
[]
[null,"申請事由３"]
[null,"Ａ","出生"]
[null,"Ｂ","被保険者資格取得"]
[null,"Ｃ","雇用保険受給終了"]
[null,"Ｄ","退職"]
[null,"Ｅ","結婚"]
[null,"Ｆ","収入減少"]
[null,"Ｇ","別居から同居によるもの"]
[null,"Ｈ","その他（扶養者１に記載）"]
[]
[]
[]
[null,"同居区分１"]
[null,"同居",{"$f":"IF(申請者入力!D45=\"同居\",\"○\",\"\")","v":""}]
[null,"別居",{"$f":"IF(申請者入力!D45=\"別居\",\"○\",\"\")","v":""}]
[]
[null,"同居区分２"]
[null,"同居",{"$f":"IF(申請者入力!D66=\"同居\",\"○\",\"\")","v":""}]
[null,"別居",{"$f":"IF(申請者入力!D66=\"別居\",\"○\",\"\")","v":""}]
[]
[null,"同居区分３"]
[null,"同居",{"$f":"IF(申請者入力!D85=\"同居\",\"○\",\"\")","v":""}]
[null,"別居",{"$f":"IF(申請者入力!D85=\"別居\",\"○\",\"\")","v":""}]
[]
[]
[null,"申立申告"]
[null,"申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）",{"$f":"IF(申請者入力!D15=\"申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）\",\"Ｖ\",\"\")","v":""}]
[null,"その他（下記余白へ記入して下さい。）",{"$f":"IF(申請者入力!D15=\"その他（下記余白へ記入して下さい。）\",\"Ｖ\",\"\")","v":""}]
[]
[]
[]
[]
[]
[null,"会社リスト",null,null,null,"1：会社で記入、２：本人記入、他"]
[null,"501．関西電力株式会社",null,null,null,2]
[null,"502．関西電力送配電株式会社",null,null,null,2]
[null,"13．かんでんＥハウス（株）",null,null,null,2]
[null,"18．（株）関電エネルギーソリューション",null,null,null,2]
[null,"19．（株）関電オフィスワーク",null,null,null,2]
[null,"31．関西電力健康保険組合",null,null,null,2]
[null,"32.関電不動産投資顧問(株)",null,null,null,2]
[null,"33.関電ガスサポート(株)",null,null,null,2]
[null,"35．Ｎｅｘｔ　Ｐｏｗｅｒ㈱",null,null,null,2]
[null,"37．関電コミュニティ（株）",null,null,null,2]
[null,"38.Newtrix Cloud Japan株式会社",null,null,null,2]
[null,"40．（株）かんでんＣＳフォーラム",null,null,null,2]
[null,"41．（株）関西メディカルネット",null,null,null,2]
[null,"44.ゲキダンイイノ合同会社",null,null,null,2]
[null,"46．（株）原子力エンジニアリング",null,null,null,2]
[null,"47.関西電子ビーム",null,null,null,2]
[null,"48．関電ファシリティーズ㈱",null,null,null,2]
[null,"49．関電プロパティーズ㈱",null,null,null,2]
[null,"61．関電プラント（株）",null,null,null,2]
[null,"62．（株）かんでんエンジニアリング",null,null,null,2]
[null,"63．（株）ＫＡＮＳＯテクノス",null,null,null,2]
[null,"67．（株）エネゲート",null,null,null,2]
[null,"69．（株）日本ネットワークサポート",null,null,null,2]
[null,"71．（株）関電アメニックス",null,null,null,2]
[null,"72．関電不動産開発（株）",null,null,null,2]
[null,"74．黒部峡谷鉄道（株）",null,null,null,2]
[null,"75．（株）ニュージェック",null,null,null,2]
[null,"76．（株）関電システムズ",null,null,null,2]
[null,"77．（株）関電Ｌ＆Ａ",null,null,null,2]
[null,"80．（株）関電パワーテック",null,null,null,2]
[null,"82．（財）関西電気保安協会",null,null,null,2]
[null,"84．関西電力労働組合",null,null,null,2]
[null,"87．関電サービス（株）",null,null,null,2]
[null,"90．（株）オプテージ",null,null,null,2]
[null,"93．（株）原子力安全ｼｽﾃﾑ研究所",null,null,null,2]
[null,"95．（株）かんでんエルハート",null,null,null,2]
[null,"98．関西電力福祉会",null,null,null,2]

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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 主 （ 事 業 主 代 理 人 ） 記 入 箇 所"]
["取扱注意",null,null,null,null,null,null,"　　　健康保険被扶養者異動届（扶養するとき）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記の通り被保険者から被扶養者の届出がありましたので提出します。"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　令和　　　　　年　　　　　月　　　　　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,null,null,null,null,"〒　　　　　　　　－"]
["健 康 保 険 組 合",null,null,null,null,null,null,null,null,null,null,null,null,"健保受付",null,null,null,null,null,"健　康　保　険　組　合　　記　入　欄"]
["　　　　長",null,null,null,"　　　　長",null,null,null,"担当者"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異動年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"補\n記\n事\n項",null,null,null,null,null,null,null,null,null,null,null,"事業所所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｈ\n\nＲ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所名称"]
[]
[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,"事業主氏名"]
[]
["関西電力健康保険組合　常務理事　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円","×",null,null,"＝",null,null,null,"万円",null,"/2＝",null,null,null,null,null,null,"電話番号"]
[]
[]
["※１（押印省略）自署の場合または確認欄の要件に該当し☑を入れた場合は、押印を省略できます。",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,"事業主確認欄（以下の内容に該当する場合は、事業主にて確認し☑願います）"]
["この届出については、①または②の要件を満たしたものです。\n①申請者本人（被保険者）が作成したものです。②記載内容について誤りがないか申請者本人が確認しています。",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,"確認欄","□",null,null,null,null,"　被保険者との続柄に関する証明書類が省略されている者については、続柄を確認しています。（内縁関係は省略不可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"確認欄","□"]
[]
["被\n\n保\n\n険\n\n者\n\n記\n\n入\n\n欄","被 保 険 者 番 号",null,null,null,null,null,null,"被保険者　氏名",null,null,null,null,null,null,null,null,null,"被保険者　生年月日",null,null,null,null,null,"所　属（※任意継続被保険者は記入不要）",null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　住　民　票　住　所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　居　所　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,null,null,null,null,null,null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,"※住民票住所と同じ場合は同上とご記入ください"]
[]
[null,"被　扶　養　者　名",null,null,null,null,null,null,null,null,null,"性\n別","続柄\n例)長男",null,"生 年 月 日",null,null,null,null,null,null,"　職業･学年　等\n例)ﾊﾟｰﾄ、高校1年生、無職",null,null,null,null,"収　入（※２）",null,null,null,null,null,null,"申　　請　　事　　由\n\n※下記申請事由の区分より選択下さい。",null,null,null,null,null,null,null,null,null,null," 扶養要件を満たした日",null,null,null,null,null,null,"同居・別居\n※別居の場合は別居理由\n　を詳しく記入下さい。\n　例）単身赴任・就学"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,"被扶養者　住　所"]
[null,"フ　　リ　　ガ　　ナ",null,null,null,null,null,null,null,null,null,"個人番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,"年　額"]
[null,"姓",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,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"給与",null,null,null,null,null,"円","区分",null,"Ａ：出生\nＢ：被保険者資格取得\nＣ：雇用保険受給終了\nＤ：退職\nＥ：結婚\nＦ：収入の減少\nＧ：別居から同居\nＨ：その他\n（下記余白へ記入願います）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同・別","（別居理由）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"住民票住所","〒",null,null,null,null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,null,null,null,null,"円"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",null,null,null,null,"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,null,null,null,null,"円"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D29,1,1)","v":""},{"$f":"MID(申請者入力!D29,2,1)","v":""},{"$f":"MID(申請者入力!D29,3,1)","v":""},{"$f":"MID(申請者入力!D29,4,1)","v":""},{"$f":"MID(申請者入力!D29,5,1)","v":""},{"$f":"MID(申請者入力!D29,6,1)","v":""},{"$f":"MID(申請者入力!D29,7,1)","v":""},{"$f":"MID(申請者入力!D29,8,1)","v":""},{"$f":"MID(申請者入力!D29,9,1)","v":""},{"$f":"MID(申請者入力!D29,10,1)","v":""},{"$f":"MID(申請者入力!D29,11,1)","v":""},{"$f":"MID(申請者入力!D29,12,1)","v":""},"その他\n(傷病手当、株配当等)",null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"給与",null,null,null,null,null,"円","区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同・別","（別居理由）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"住民票住所","〒",null,null,null,null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,null,null,null,null,"円"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",null,null,null,null,"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(+申請者入力!D43=\"\",\"\",申請者入力!D43)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D50,1,1)","v":""},{"$f":"MID(申請者入力!D50,2,1)","v":""},{"$f":"MID(申請者入力!D50,3,1)","v":""},{"$f":"MID(申請者入力!D50,4,1)","v":""},{"$f":"MID(申請者入力!D50,5,1)","v":""},{"$f":"MID(申請者入力!D50,6,1)","v":""},{"$f":"MID(申請者入力!D50,7,1)","v":""},{"$f":"MID(申請者入力!D50,8,1)","v":""},{"$f":"MID(申請者入力!D50,9,1)","v":""},{"$f":"MID(申請者入力!D50,10,1)","v":""},{"$f":"MID(申請者入力!D50,11,1)","v":""},{"$f":"MID(申請者入力!D50,12,1)","v":""},"その他\n(傷病手当、株配当等)",null,null,null,null,null,"円"]
[null,"遡及理由（届出遅延理由）申立書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"共同扶養する他保険や他組合の被保険者の年収確認"]
[]
[]
[null,"遡って認定すべき理由が有る場合は、下記へ記入（チェック）して下さい。\n※原則は健康保険組合受付日が認定日です。必ず遡及できるとは限りません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"上記被扶養者を認定するにあたって、共同で生活を支えている方（共同扶養者）※が存在する場合、申請者（被保険者）と共同で\n生活を支えている方（共同扶養者）と双方の収入を確認しますので、「共同扶養における収入額確認表」と必要書類を添付して\nください。\n※該当する方\n　被扶養者になっていない配偶者・届出しようとしている被扶養者と同一世帯である他健保等の被保険者（父母、兄弟、姉妹等）"]
[]
[]
[]
[]
[null,"□","申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）"]
[null,"□","その他（下記余白へ記入して下さい。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入にあたっての留意点（ご一読下さい）"]
[null,{"$f":"+[1]申請者入力!D16","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","届出内容に誤りや虚偽の内容があった場合、被扶養者の認定そのものを取り消すことがあります。\nその間に使用された医療費は全額お返しいただきます。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　※署名は直筆で記入願います。\n氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","個人番号については、健康保険届出事務に関して利用するものです。"]
[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,"補足事項"]
[null,null,"上記の事実に相違ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※２：収入は届出時点から向こう１年間の見込み額を記入してください。"]
[]
[null,"ご記入いただいた個人情報は、当該の利用目的以外には使用いたしません。",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,null,null,null,null,null,null,null,null,null,null,null,"令和６年２月更新"]

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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 主 （ 事 業 主 代 理 人 ） 記 入 箇 所"]
["取扱注意",null,null,null,null,null,null,"　　　健康保険被扶養者異動届（扶養するとき）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記の通り被保険者から被扶養者の届出がありましたので提出します。"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　令和　　　　　年　　　　　月　　　　　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,null,null,null,null,"〒　　　　　　　　－"]
["健 康 保 険 組 合",null,null,null,null,null,null,null,null,null,null,null,null,"健保受付",null,null,null,null,null,"健　康　保　険　組　合　　記　入　欄"]
["　　　　長",null,null,null,"　　　　長",null,null,null,"担当者"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異動年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"補\n記\n事\n項",null,null,null,null,null,null,null,null,null,null,null,"事業所所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号",null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｈ\n\nＲ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所名称"]
[]
[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,"事業主氏名"]
[]
["関西電力健康保険組合　常務理事　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円","×",null,null,"＝",null,null,null,"万円",null,"/2＝",null,null,null,null,null,null,"電話番号"]
[]
[]
["※１（押印省略）自署の場合または確認欄の要件に該当し☑を入れた場合は、押印を省略できます。",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,"事業主確認欄（以下の内容に該当する場合は、事業主にて確認し☑願います）"]
["この届出については、①または②の要件を満たしたものです。\n①申請者本人（被保険者）が作成したものです。②記載内容について誤りがないか申請者本人が確認しています。",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,"確認欄","□",null,null,null,null,"　被保険者との続柄に関する証明書類が省略されている者については、続柄を確認しています。（内縁関係は省略不可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"確認欄","□"]
[]
["被\n\n保\n\n険\n\n者\n\n記\n\n入\n\n欄","被 保 険 者 番 号",null,null,null,null,null,null,"被保険者　氏名",null,null,null,null,null,null,null,null,null,"被保険者　生年月日",null,null,null,null,null,"所　属（※任意継続被保険者は記入不要）",null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　住　民　票　住　所"]
[null,1,2,null,null,2,null,null,"関西　太郎",null,null,null,null,null,null,null,"※１",null,"昭和52.4.1",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒","123-4567"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大阪市北区中之島６丁目2-7"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被　保　険　者　居　所　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,null,null,null,null,null,null,null,"〒","123-4567",null,null,null,null,null,null,null,null,null,null,null,"※住民票住所と同じ場合は同上とご記入ください\t\t\t\t\t"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同上"]
[null,"被　扶　養　者　名",null,null,null,null,null,null,null,null,null,"性\n別","続柄\n例)長男",null,"生 年 月 日",null,null,null,null,null,null,"　職業･学年　等\n例)ﾊﾟｰﾄ、高校1年生、無職",null,null,null,null,"収　入（※２）",null,null,null,null,null,null,"申　　請　　事　　由\n\n※下記申請事由の区分より選択下さい。",null,null,null,null,null,null,null,null,null,null," 扶養要件を満たした日",null,null,null,null,null,null,"同居・別居\n※別居の場合は別居理由\n　を詳しく記入下さい。\n　例）単身赴任・就学"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"号","年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,"被扶養者　住　所"]
[null,"フ　　リ　　ガ　　ナ",null,null,null,null,null,null,null,null,null,"個人番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,"年　額"]
[null,"姓",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,null,null,null,"号","年",null,"月",null,"日"]
[null,"ｶﾝｻｲ",null,null,null,null,"サブロウ",null,null,null,null,"男","長男",null,"2003-12-01",null,null,null,null,null,null,"学生",null,null,null,null,"給与",null,600000,null,null,null,"円","区分",null,"Ａ：出生\nＢ：被保険者資格取得\nＣ：雇用保険受給終了\nＤ：退職\nＥ：結婚\nＦ：収入の減少\nＧ：別居から同居\nＨ：その他\n（下記余白へ記入願います）",null,null,null,null,null,null,null,null,"R",0,null,null,null,null,null,"同・別","（別居理由）"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"就学"]
[null,"関西",null,null,null,null,"三郎",null,null,null,null,"住民票住所","〒","123-4567",null,null,null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,0,null,null,null,"円","B"]
[null,null,null,null,null,null,null,null,null,null,null,null,"東京都千代田区一ツ橋"]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒","123-4567",null,null,null,"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,0,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"東京都千代田区一ツ橋"]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D29,1,1)","v":""},{"$f":"MID(申請者入力!D29,2,1)","v":""},{"$f":"MID(申請者入力!D29,3,1)","v":""},{"$f":"MID(申請者入力!D29,4,1)","v":""},{"$f":"MID(申請者入力!D29,5,1)","v":""},{"$f":"MID(申請者入力!D29,6,1)","v":""},{"$f":"MID(申請者入力!D29,7,1)","v":""},{"$f":"MID(申請者入力!D29,8,1)","v":""},{"$f":"MID(申請者入力!D29,9,1)","v":""},{"$f":"MID(申請者入力!D29,10,1)","v":""},{"$f":"MID(申請者入力!D29,11,1)","v":""},{"$f":"MID(申請者入力!D29,12,1)","v":""},"その他\n(傷病手当、株配当等)",null,0,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"給与",null,null,null,null,null,"円","区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同・別","（別居理由）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"住民票住所","〒",null,null,null,null,"※被保険者の住民票住所と別の場合に記入",null,null,null,null,null,null,null,null,"年金",null,null,null,null,null,"円"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"居所\n住所","〒",null,null,null,null,"※被保険者の居所住所と別の場合に記入",null,null,null,null,null,null,null,null,"事業",null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(+申請者入力!D43=\"\",\"\",申請者入力!D43)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,{"$f":"MID(申請者入力!D50,1,1)","v":""},{"$f":"MID(申請者入力!D50,2,1)","v":""},{"$f":"MID(申請者入力!D50,3,1)","v":""},{"$f":"MID(申請者入力!D50,4,1)","v":""},{"$f":"MID(申請者入力!D50,5,1)","v":""},{"$f":"MID(申請者入力!D50,6,1)","v":""},{"$f":"MID(申請者入力!D50,7,1)","v":""},{"$f":"MID(申請者入力!D50,8,1)","v":""},{"$f":"MID(申請者入力!D50,9,1)","v":""},{"$f":"MID(申請者入力!D50,10,1)","v":""},{"$f":"MID(申請者入力!D50,11,1)","v":""},{"$f":"MID(申請者入力!D50,12,1)","v":""},"その他\n(傷病手当、株配当等)",null,null,null,null,null,"円"]
[null,"遡及理由（届出遅延理由）申立書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"共同扶養する他保険や他組合の被保険者の年収確認"]
[]
[]
[null,"遡って認定すべき理由が有る場合は、下記へ記入（チェック）して下さい。\n※原則は健康保険組合受付日が認定日です。必ず遡及できるとは限りません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"上記被扶養者を認定するにあたって、共同で生活を支えている方（共同扶養者）※が存在する場合、申請者（被保険者）と共同で\n生活を支えている方（共同扶養者）と双方の収入を確認しますので、「共同扶養における収入額確認表」と必要書類を添付して\nください。\n※該当する方\n　被扶養者になっていない配偶者・届出しようとしている被扶養者と同一世帯である他健保等の被保険者（父母、兄弟、姉妹等）"]
[]
[]
[]
[]
[null,"□","申請書類を揃えるまでに時間を要した。（離職票や喪失証明書が発行されない場合等。）"]
[null,"□","その他（下記余白へ記入して下さい。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入にあたっての留意点（ご一読下さい）"]
[null,{"$f":"+[1]申請者入力!D16","v":"00:00:00"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","届出内容に誤りや虚偽の内容があった場合、被扶養者の認定そのものを取り消すことがあります。\nその間に使用された医療費は全額お返しいただきます。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　※署名は直筆で記入願います。\n氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,"〇","個人番号については、健康保険届出事務に関して利用するものです。"]
[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,"補足事項"]
[null,null,"上記の事実に相違ありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※２：収入は届出時点から向こう１年間の見込み額を記入してください。"]
[]
[null,"ご記入いただいた個人情報は、当該の利用目的以外には使用いたしません。",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,null,null,null,null,null,null,null,null,null,null,null,"令和６年２月更新"]