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["【一般用】\n生計維持調査票（表）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"この「生計維持調査票」は、被保険者(職員本人)であるあなたからみて、新たに被扶養者（家族）として申請される方および、既に被扶養者資格のある方との身分関係や生計維持関係(生活費等の依存度)を記入していただくものです。審査する上で重要な資料となりますので、具体的にわかりやすく記入をお願いします。"]
[]
[]
[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,"※←データクリアを押すと、入力されているデータが削除されます。"]
[]
[]
["下記の記入内容に間違いありません",null,null,null,null,null,null,null,null,null,null,null,null,"被 保 険 者",null,null,null,"（職員本人）",null,null,null,"氏名",null,null,null,null,null,null,null,null,"記入日",null,null,null,"年",null,"月",null,"日"]
["記号（　　　　　　　）",null,null,null,")",null,"番号（　　　　　　　　）",null,null,null,")",null,null,"扶養申請者",null,null,null,"　　被扶養者になろうと\n　　している人",null,null,null,"氏名",null,null,null,null,null,null,null,null,"年齢",null,null,null,"歳",null,"続柄"]
[]
[]
["該当する項目に✔または記入してください。必ず記入漏れがないようにお願いします。"]
[1,"今回、被扶養者として申請する理由を記入してください。※複数回答可"]
[]
[null,null,"被保険者(私)が資格を取得したため",null,null,null,null,null,null,null,null,null,null,null,null,"取得年月日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,false]
[null,null,"結婚のため",null,null,null,null,null,null,null,null,null,null,null,null,"入籍年月日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,false]
[null,null,"会社を退職したため",null,null,null,null,null,null,null,null,null,null,null,null,"退職年月日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,false]
[null,null,"出産を控えているため",null,null,null,null,null,null,null,null,null,null,null,null,"出産（予定）年月日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,false]
[null,null,"失業保険の受給を終了したため",null,null,null,null,null,null,null,null,null,null,null,null,"受給終了年月日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,false]
[null,null,"学生のため（高校生以上は在学証明書または学生証のコピーを添付）"]
[null,null,null,null,"中学生以下",null,null,null,null,"高校生",null,null,null,null,"大学（院）生",null,null,null,null,null,"専門学校生"]
[null,null,null,null,null,null,null,null,null,"高校生以上の場合、",null,null,null,null,null,"学校名　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,"卒業予定",null,null,null,null,"年",null,null,"月",null,null,null,null,null,null,null,false]
[null,null,"収入が少ない／無収入のため",null,null,null,null,null,null,null,null,null,null,null,null,null,null,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]
[null,null,"今まで扶養していた家族の退職や、離婚などにより、被保険者（私）に扶養異動する為",null,null,null,null,null,null,null,null,null,null,null,null,null,null,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]
[null,null,"その他",null,null,"（具体的にご記入ください　　　　  　　　　　　　　　　　　　　　　       　　　　　                                                         ",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,false]
[]
[2,"現在加入中または加入していた健康保険について記入してください。"]
[]
[null,null,"国民健康保険",null,null,null,null,null,"協会けんぽ",null,null,null,null,null,"健康保険組合",null,null,null,null,null,"共済組合"]
[]
[3,"今までと今後の生活費の出所やその他の生計状況など詳しく記入してください。"]
["今まで"]
[null,null,null,null,null,"お互いの収入から出し合って生活していた"]
[null,null,null,null,null,"扶養申請者に収入が無い、または収入が少ない為、",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（続柄",null,null,null,"）の収入で生活をしていた",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,"今まで健康保険は",null,null,null,null,null,null,"私の扶養として加入していた",null,null,null,null,null,null,null,null,null,null,"（続柄",null,null,null,"）の扶養として加入していた",null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,"扶養申請者自身の収入を主として生活をしていた"]
[null,null,null,null,null,"その他",null,null,"（具体的にご記入ください　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",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,false]
[]
["今後"]
[null,null,null,null,null,"扶養申請者が退職し無収入になった、または収入が減った為、今後は私の収入を主として生活していく"]
[null,null,null,null,null,"私からも生活費の支援は行うが、扶養申請者の収入や貯蓄を主として生活していく"]
[null,null,null,null,null,"今までと変わらず、私の収入で生活していく"]
[null,null,null,null,null,"今までと変わらず、",null,null,null,null,null,"（続柄",null,null,null,"／※被保険者以外）からの生活費の支援を主として生活していく",null,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]
[null,null,null,null,null,"その他　　　　　　　",null,null,"（具体的にご記入ください　",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,false]
[]
[4,"今後、被保険者から生活費の半分程度以上の支援を受ける状況はいつまで続きそうですか。"]
[]
[null,null,"当面は収入が無い（少ない）為、しばらく続く",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"就職先が見つかるまで（就職活動中）",null,null,null,null,null,null,null,null,null,null,null,null,"学校を卒業し就職するまで"]
[null,null,"既に次の就職先が決まっている為、再就職するまでの間"]
[]
[5,"扶養申請者に配偶者はいますか。（扶養申請者が被保険者の「妻」または「夫」の場合は記入不要）"]
[]
[null,null,"はい",null,"（配偶者の収入がわかる書類を添付）",null,null,null,null,null,null,null,null,null,null,"いいえ",null,null,null,"未婚",null,null,"離婚（",null,null,null,"年",null,null,"月）",null,"死別（",null,null,null,"年",null,null,"月）",null,null,false]
[]
[6,"住居について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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]
[]
[null,null,"同一住宅に同居"]
[]
[null,null,"２世帯住宅または共同住宅の別戸(生計維持の証明を添付)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※生計維持の証明…仕送りをしている通帳の写し、扶養申請者の家賃等を被保険者の口座から支払っていることが確認できる証明書類など"]
[null,null,"同一敷地内の別棟（生計維持の証明を添付）"]
[null,null,"別居（生計維持の証明を添付。ただし、学生の場合は原則不要）",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,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,"①","生計維持状況",null,null,null,null,null,"仕送り(送金)額",null,null,null,null,null,null,null,null,"万円／月"]
[null,null,null,null,null,null,null,null,null,null,"扶養申請者の住居費を被保険者が支払っている場合",null,null,null,null,null,null,null,null,null,null,null,"家賃",null,null,null,null,"万円／月・水道光熱費",null,null,null,null,null,null,null,null,null,"万円／月"]
[]
[null,null,null,"②","別居している理由",null,null,null,null,null,null,"単身赴任",null,null,null,null,"通学",null,null,null,"施設入所等",null,null,null,"（施設名称）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,"その他",null,null,"具体的理由",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,false]
[]
[null,null,null,"③","別居先で扶養申請者は誰と同居していますか（被保険者からみた続柄）"]
[null,null,null,null,null,"1人暮らし",null,null,null,null,"その他（続柄",null,null,null,null,null,null,null,null,null,"）","合計",null,null,null,"人",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
["【一般用】\n生計維持調査票（裏）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　健保組合で個人番号を使用して所得情報等を照会する場合が\n　あります。収入状況等は正確にご記入ください。"]
[]
[]
[]
[]
["※該当する項目に✔または記入してください。必ず記入漏れがないようにお願いします。"]
[7,"扶養申請者の今後の収入の有無について（①～⑥まですべてご回答ください）"]
["①","勤労収入"]
[null,null,null,null,null,null,null,"あり（直近三ヶ月の給与明細を添付）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,"月平均労働日数",null,null,null,null,null,null,"日","(１日あたりの勤務時間",null,null,null,null,null,null,null,null,"時間)",null,null,"月平均給与(総額支給額)",null,null,null,null,null,null,null,null,"万円位/月"]
[null,null,null,null,null,null,null,null,"※申請者が自営業・農業の「専従者」の場合、こちらにご記入ください。"]
[null,null,null,null,null,null,null,null,"※働き始めて間もない等の理由で直近三ヶ月の実績がない方は雇用契約書を添付"]
["②","自営業収入"]
[null,null,null,null,null,null,null,"あり（直近の確定申告書A・B、収支内訳書の写を添付）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,"業種",null,null,null,null,null,null,null,null,"/年間収入額（経費を差し引いていない額）",null,null,null,null,null,null,null,null,null,null,null,null,null,"万円（見込含）"]
[null,null,null,null,null,null,null,null,"※自営業を始めて間もない等の理由で確定申告関係書類がない方は売上等がわかる書類を添付"]
["③","農業収入"]
[null,null,null,null,null,null,null,"あり（直近の確定申告書A・B、収支内訳書の写を添付）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,"田畑の内容",null,null,null,null,null,null,"耕作面積",null,null,null,null,"アール",null,null,"年間収入額（経費を差し引いていない額）",null,null,null,null,null,null,null,null,null,null,null,null,"万円(見込含)"]
[null,null,null,null,null,null,null,null,"※農業を始めて間もない等の理由で確定申告関係書類がない方は売上などがわかる書類を添付"]
["④","年金収入"]
[null,null,null,null,null,null,null,"あり（支払通知書の写しを添付）",null,null,null,null,null,null,null,null,null,null,null,"今後１年以内に受給予定（",null,null,null,null,null,null,null,null,null,"年",null,null,"月から）",null,null,null,null,"なし",null,null,null,false]
[]
[null,null,null,null,null,null,null,null,"\n\n年金の種類\n"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"老齢年金",null,null,"（",null,"国民",null,null,"厚生",null,null,"その他",null,null,"）",null,null,null,"年額",null,null,null,null,null,"円",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"遺族年金",null,null,"（",null,"国民",null,null,"厚生",null,null,"その他",null,null,"）",null,null,null,"年額",null,null,null,null,null,"円",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"障害年金",null,null,"（",null,"国民",null,null,"厚生",null,null,"その他",null,null,"）",null,null,null,"年額",null,null,null,null,null,"円",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"企業年金",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,null,null,null,null,"円",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人年金",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年額",null,null,null,null,null,"円",null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他",null,null,"（種類",null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"年額",null,null,null,null,null,"円",null,null,false]
[]
["⑤","雇用保険"]
[null,null,null,null,null,null,null,"あり（後日、離職票または受給資格者証を提出）",null,null,null,null,null,null,null,null,null,null,null,null,"なし"]
[null,null,null,null,null,null,null,null,null,"受給予定",null,null,null,null,null,null,null,null,null,null,null,null,"加入していなかった（働いていた時の給与明細の写を添付）　"]
[null,null,null,null,null,null,null,null,null,"延長",null,null,null,null,null,null,null,null,null,null,null,null,"加入期間不足（前勤務先の離職票を提出）"]
[null,null,null,null,null,null,null,null,null,"放棄",null,null,null,null,null,null,null,null,null,null,null,"加入期間",null,null,null,"年",null,null,"月","～",null,null,"年",null,null,"月",null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受給終了（雇用保険受給資格者証（両面写し）を添付）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他（理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,false]
[]
["⑥","その他収入"]
[null,null,null,null,null,null,null,"あり（証明する書類を添付）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なし"]
[null,null,null,null,null,null,null,null,null,"不動産収入（家賃収入など）",null,null,null,null,null,null,null,null,null,"（",null,null,"年分）",null,"年間収入額（経費を差し引いていない額）",null,null,null,null,null,null,null,null,null,null,null,null,null,"万円",null,null,false]
[null,null,null,null,null,null,null,null,null,"配当所得",null,null,null,null,null,null,null,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,false]
[null,null,null,null,null,null,null,null,null,"被保険者以外からの仕送り",null,null,null,null,null,null,null,null,null,"支援者氏名",null,null,null,null,null,null,null,null,null,null,"続柄（",null,null,null,"）",null,null,null,"万円",null,null,false]
[null,null,null,null,null,null,null,null,null,"傷病手当金",null,null,null,null,"（傷病名　　　　",null,null,null,null,null,null,null,null,null,"/","受給開始",null,null,null,null,"年",null,null,"月～）",null,null,null,null,"万円",null,null,false]
[null,null,null,null,null,null,null,null,null,"その他",null,null,"内容",null,null,null,null,null,null,"（",null,null,"年分）",null,"年間収入額（経費を差し引いていない額）",null,null,null,null,null,null,null,null,null,null,null,null,null,"万円",null,null,false]
[]
[8,"家族構成について　※扶養申請者が複数名（生計維持調査票を複数人分記入する場合）の場合、「８ 家族構成について」は2枚目以降省略可"]
["氏     名",null,null,null,null,null,null,null,null,null,"続柄",null,null,null,"年齢",null,null,null,"勤務先・学校名（学年）",null,null,null,null,null,null,null,null,null,null,"今後の年収額",null,null,null,null,null,null,"同 別 居"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[]
["事業所名証明欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者の年収額"]
[null,"事業所扶養手当支給の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"源泉徴収における扶養家族該当の有無"]
[null,"【","有","】","（支給　　開始　・　開始予定",null,null,null,null,null,null,null,null,"年",null,"月）",null,"【","有","】","（　　該当　・　該当予定",null,null,null,null,null,null,null,"年",null,"月）",null,null,null,null,null,null,null,"万円"]
[null,"【","無","】","（理由",null,null,null,null,null,null,null,null,null,null,null,"）","【","無","】","（理由",null,null,null,null,null,null,null,null,null,null,"）"]
[null,"□","この届出については、申請者本人（被保険者）が作成、または記載内容について本人が確認しています。※チェック必須"]
[null,"記載事項は、事実と相違ないことを証明します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,"年",null,"月",null,"日"]
["事業所名"]
[]
["事業主名"]
[]
[null,"静岡県農業団体健康保険組合　理事長　殿"]
["【備考】"]