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{"sheet":"出生用 ","index":0,"n_rows":71,"n_cols":51,"rows_kept":71,"cut":false,"hidden":false,"merged":[[65,5,66,23],[67,5,68,23],[41,25,42,37],[47,13,47,14],[49,13,49,14],[47,16,47,17],[47,19,47,20],[47,27,47,28],[47,30,47,31],[47,33,47,34],[49,16,49,17],[49,19,49,20],[49,27,49,28],[49,30,49,31],[49,33,49,34],[39,22,40,22],[39,23,40,23],[41,12,42,14],[41,16,42,22],[39,17,40,17],[39,18,40,18],[39,19,40,19],[39,20,40,20],[39,21,40,21],[29,12,30,15],[37,9,37,16],[39,12,40,12],[39,13,40,13],[39,14,40,14],[39,15,40,15],[39,16,40,16],[27,5,28,8],[27,9,28,17],[12,7,12,16],[12,19,12,20],[12,23,12,32],[8,32,8,33],[8,35,8,36],[10,2,10,10],[10,11,10,20],[10,21,10,22],[10,23,10,24],[51,5,54,36],[62,6,62,14],[62,21,62,29],[65,0,66,4],[0,0,4,15],[29,5,30,11],[30,16,30,17],[0,16,4,38],[8,2,8,3],[8,7,8,9],[8,18,8,25],[8,27,8,28],[8,29,8,30],[65,27,66,32],[56,27,56,36],[12,35,12,36],[63,2,63,32],[67,31,69,32],[67,27,69,30],[71,0,72,38],[8,11,8,17],[61,4,61,10],[67,0,68,4],[39,5,40,11],[41,5,42,10],[47,4,49,8],[47,11,47,12],[47,22,47,24],[47,25,47,26],[49,11,49,12],[49,22,49,24],[49,25,49,26]]}
["【出生用】\n生計維持調査票",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"夫婦共働きで子供がいる場合には「共同扶養」となり、原則として年間収入が多い方の扶養となります。この「生計維持調査票」では、被保険者であるあなたとその配偶者の収入等を比較し、新たに被扶養者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、間違いのないよう記入してください。"]
[]
[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,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。"]
[]
[]
[]
[]
["保険証の記号と番号"]
["記号（　　　　　　）",null,null,null,"）","番号（　　　　　　　　）",null,null,null,null,")","被保険者（職員本人）署名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,"扶養申請者（出生した子）氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続柄（",null,null,null,"）"]
[null,null,"（多胎の場合）"]
[null,null,"扶養申請者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続柄（",null,null,null,"）","・",null,null,null,null,null,null,null,null,null,null,"続柄（",null,null,null,"）"]
[]
[]
["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。"]
[]
[null,null,"出生のため（母子手帳の写または世帯全員の住民票を添付）"]
[]
[2,"あなた（被保険者）の配偶者について　※内縁関係含む"]
[]
[null,null,"配偶者あり"]
[]
[null,null,null,null,null,"農団健保に家族（被扶養者）として加入している"]
[]
[null,null,null,null,null,"農団健保に家族（被扶養者）として加入していない　※配偶者も被保険者として農団健保に加入している場合を含む"]
[null,null,null,null,null,"配偶者の氏名"]
[]
[null,null,null,null,null,"配偶者の年間収入"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[]
[null,null,null,null,null,null,"給与収入（源泉徴収票の写しまたは金額がわかる書類を添付）"]
[null,null,null,null,null,null,"自営業による収入（直近の確定申告書の写、収支内訳書を添付）"]
[null,null,null,null,null,null,"農業収入（直近の確定申告書の写、収支内訳書を添付）"]
[null,null,null,null,null,null,"不動産収入（直近の確定申告書の写、収支内訳書を添付）"]
[null,null,null,null,null,null,"年金収入（年金振込通知書または金額がわかる書類を添付）"]
[null,null,null,null,null,null,"その他（　　　　　　　　　　　　　　　　）（金額がわかる書類を添付）"]
[]
[null,null,null,null,null,"配偶者のマイナンバー"]
[]
[null,null,null,null,null,"配偶者の住所\n（住所が異なる場合）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"市","区"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"県",null,null,null,null,null,null,null,"町","村"]
[]
[]
[null,null,null,null,null,"あなた（被保険者）もしくは配偶者が育児休業を取得(予定)の場合はご記入ください"]
[]
[null,null,null,null,"育児休業期間",null,null,null,null,"夫",null,"令和",null,null,null,"年",null,null,"月",null,null,"日","～",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,null,null,null,null,null,null,"妻",null,"令和",null,null,null,"年",null,null,"月",null,null,"日","～",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,null,null,"※配偶者のマイナンバーにより、収入に関する情報を照会する場合があります。また、今後、配偶者の年間\n　 収入があなた(被保険者)の年間収入を超えることが明らかになった場合には、速やかに被扶養者資格の\n 　喪失手続きを　行う必要があります。"]
[]
[]
[]
[]
[null,null,"配偶者なし",null,null,null,"（　",null,null,"未婚　",null,null,null,"離婚",null,"（",null,"年",null,"月","）",null,null,"その他",null,null,"（",null,null,null,null,null,null,null,null,null,null,"）","）"]
[]
[]
["事業所名証明欄",null,null,null,null,null,"※任意継続被保険者は記入不要"]
[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,"住民税の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,"年",null,"月）",null,"【","有","】","（　　該当　・　該当予定",null,null,null,null,null,null,null,"年",null,"月）"]
[null,"【","無","】","（理由",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,"令和",null,"年",null,"月",null,"日"]
["事業所名",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,"被保険者の年収額"]
[]
["事業主名",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,"万円"]
[]
[null,"静岡県農業団体健康保険組合　理事長　殿"]
["【備考】"]