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{"sheet":"説明・申立書","index":0,"n_rows":158,"n_cols":50,"rows_kept":158,"cut":false,"hidden":false,"merged":[[70,2,75,7],[70,38,70,50],[71,38,75,50],[73,18,73,22],[75,14,75,36],[61,2,61,21],[63,2,68,7],[63,38,63,50],[64,38,64,45],[64,46,65,50],[65,38,65,45],[66,38,66,50],[67,38,67,50],[68,38,68,50],[54,30,54,44],[54,46,54,50],[55,20,56,45],[55,46,59,50],[57,19,57,23],[57,38,57,42],[58,33,58,44],[59,35,59,39],[58,26,58,32],[50,8,51,19],[50,36,50,45],[50,46,50,50],[51,40,51,44],[51,46,52,50],[52,31,52,44],[52,20,52,30],[44,46,48,50],[45,20,45,25],[45,26,45,29],[48,14,48,44],[39,35,39,38],[39,39,39,44],[39,46,39,50],[40,35,40,38],[40,39,40,44],[40,46,40,50],[41,14,41,33],[41,35,41,38],[41,39,41,44],[41,46,41,50],[43,46,43,50],[37,35,37,38],[37,39,37,44],[37,46,37,50],[38,35,38,38],[38,39,38,44],[38,46,38,50],[33,14,33,23],[35,35,35,45],[35,46,35,50],[36,35,36,38],[36,39,36,44],[36,46,36,50],[31,35,31,50],[16,2,16,47],[18,21,18,27],[21,48,27,48],[21,49,27,50],[22,18,27,21],[22,24,22,33],[22,44,22,45],[24,4,24,15],[24,24,24,33],[24,44,24,45],[26,6,26,9],[26,13,26,14],[26,24,26,33],[26,44,26,45],[29,2,29,50],[1,3,1,49],[11,2,11,50],[14,2,14,9],[14,10,14,13],[14,15,14,17],[14,18,14,21],[14,22,14,28],[14,29,14,40]]}
[]
[null,null,null,"「扶養状況説明書（申立書）」 入力上の注意"]
[]
[null,null,null,"この書類は、",null,null,null,null,"①","被扶養者の認定時に提出していただく書類です。削除する場合は必要ありません。"]
[null,null,null,null,null,null,null,null,"②","日本国内に住所を有している被扶養者用です。"]
[null,null,null,null,null,null,null,null,"③","被保険者が作成してください。"]
[null,null,null,null,null,null,null,null,"④","認定対象者ごとに１枚作成してください。ただし、高校生以下で無収入の「子」は連名で記入できます。"]
[]
[null,null,null,"この書類で「要添付書類」としている書類を添付してください。なお、記号は別紙でご確認願います。"]
[]
[]
[null,null,"扶養状況説明書（申立書）"]
[]
[]
[null,null,"被保険者証の記号",null,null,null,null,null,null,null,null,null,null,null,null,"番号",null,null,null,null,null,null,"被保険者氏名"]
[]
[null,null,"私は、被扶養者認定に関して、次のとおり申し立てます。"]
[]
[null,null,null,"被保険者の年収（賞与・年金等含む総収入額）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,"要添付書類","Ｒ"]
[null,null,null,"認定対象者の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null," 高校生\n 以下で\n 無収入\n の子",null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,null,null,null,"年齢",null,null,"歳"]
[]
[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",null,null,null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,null,null,null,"年齢",null,null,"歳"]
[]
[null,null,null,null,null,"続柄",null,null,null,null,null,null,"年齢",null,null,"歳",null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,null,null,null,"年齢",null,null,"歳"]
[]
[]
[null,null,"下記の➊～➐に入力してください。　ただし、高校生以下で無収入の子については➊、➍、➐のみ入力してください。 "]
[]
[null,null," ➊ 届出の理由",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,null,null,null,null,null,null,"「その他」の場合に記入"]
[]
[null,null," ➋ 上記の事由に該当した日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（入力例 ： 10/25 のように入力）"]
[]
[null,null,null,null,null,null,null,null,"　現在の収入状況　（該当するすべての項目に☑し金額を入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"収　入　額",null,null,null,null,null,null,null,null,null,null,"要添付書類"]
[null,null,null,null,null,null,null,null,null,null,"給与収入",null,null,null,"（ ",null,"パート",null,null,null,null,"アルバイト",null,null,null,null,null,"　その他 ）",null,null,null,null,null,null,null,"平均月額",null,null,null,null,null,null,null,null,null,"円","Ｃ と 学生はＢ"]
[null,null,null,null,null,null,null,null,null,null,"年金",null,"（",null," 老齢",null,null,null,"障害",null,null,"　 遺族 ）を受給(手続)中",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","Ｄ"]
[null,null,null,null,null,null,null,null,null,null,"雇用保険の失業給付を受給中",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日　額",null,null,null,null,null,null,null,null,null,"円","Ｇ"]
[null,null,null,null,null,null,null,null,null,null,"健康保険の傷病または出産手当金を受給(手続)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,"日　額",null,null,null,null,null,null,null,null,null,"円","Ｋ"]
[null,null,null,null,null,null,null,null,null,null,"事業収入",null,null,null,"（ ",null,"自営",null,null,null,"不動産",null,null,null," その他 ）",null,null,null,null,null,null,null,null,null,null,"年　額",null,null,null,null,null,null,null,null,null,"円","Ｌ"]
[null,null,null,null,null,null,null,null,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,"]","年　額",null,null,null,null,null,null,null,null,null,"円","Ｍ"]
[]
[null,null,null,null,null,null,null,null,"　現在の状況　（該当する項目に☑および入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要添付書類"]
[null,null,null,null,null,null,null,null,null,null,"無職",null,null,null,"就労予定無し",null,null,null,null,null,null,"就職活動中 ➝",null,null,null,null,null,"雇用保険失業給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 Ａ と Ｓ\n\n  ただし、\n  学生はB\n  のみで可"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"妊娠・育児中",null,null,null,null,null,"出産(予定)日：",null,null,null,null,null,null,null,null,null," ➝ 出産手当金の受給権"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病気療養中",null,null,null,null,"➝  傷病手当金・障害年金の受給"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"学生（アルバイト等の収入なし）"]
[null,null,null,null,null,null,null,null,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,null,null,null,null," 同居者で被保険者と認定対\n 象者以外に収入のある方が",null,null,null,null,null,null,null,null,null,null,null,"その方（複数いる場合は最高収入者）との続柄 ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要添付書類"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その方の収入",null,null,null,null,null,null,"給与",null,null," 年金",null,null,"　他",null,null,null,null,null,"合計年収 約",null,null,null,null,null,"円","Ｎ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その方が扶養できない理由 [",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," 別居の理由は",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他 [",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"]","要添付書類"]
[null,null,null,null,null,null,null,null," 認定対象者と同居する人が",null,null,null,null,null,null,null,null,null,null,null,"その方の認定対象者に対する金銭的支援",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"   Ｎ と\n   Ｏ か Ｐ\n\n  "]
[]
[null,null,null,null,null,null,null,null," 認定対象者の生活費",null,null,null,null,null,null,null,null,"月額",null,null,null,null,null,null,"円",null,null,null," 被保険者の仕送額",null,null,null,null,null,null,null,"月額",null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null," 被保険者以外に認定対象者へ仕送り",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その方との続柄[",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"]"]
[null,null,null,null,null,null,null,null," している人が",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その方の仕送額",null,null,null,null,null,null,null,"月額",null,null,null,null,null,"円"]
[]
[null,null," ➎　認定対象が父母のいずれか一方の場合のみ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"認定対象者の配偶者は"]
[]
[null,null," ➏\n 認定対象者\n が退職後\n ４年以内の\n 場合のみ\n 記入",null,null,null,null,null," 雇用保険失業給付について",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,"要添付書類"]
[null,null,null,null,null,null,null,null,null,null,"失業給付は受給できない",null,null,null,null,null,null,null,null,null,null,null,"理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｇ か Ｅ か Ｆ か Ｉ",null,null,null,null,null,null,null,"ただし、退職後1年を経過しているときは不要"]
[null,null,null,null,null,null,null,null,null,null,"就労する意思がないため受給手続きを行わない",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,"（Ｅ か Ｆ か Ｇ） と Ｊ"]
[null,null,null,null,null,null,null,null,null,null,"ハローワークで手続き中だが、現在 待期・給付制限期間中",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（Ｅ か G） と  Ｊ"]
[null,null,null,null,null,null,null,null,null,null,"ハローワークで手続き中だが、現在 受給期間延長中（出産、育児、疾病等）",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,"（Ｅ と Ｊ） か （Ｇ と Ｈ と Ｊ）"]
[null,null,null,null,null,null,null,null,null,null,"現在 受給している",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,"Ｇ"]
[]
[null,null," ➐\n 認定対象者\n が子の場合\n のみ記入",null,null,null,null,null," 被保険者の配偶者が被扶養者にできない理由",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,"要添付書類"]
[null,null,null,null,null,null,null,null,null,null,"配偶者は無収入または被保険者より収入が少ない",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,"  配偶者に収入がある場合は、\n  配偶者の CかL\n  ただし、配偶者が当組合の被\n  扶養者である場合は不要です"]
[null,null,null,null,null,null,null,null,null,null,null,"配偶者は当組合の被扶養者に"]
[null,null,null,null,null,null,null,null,null,null,null,"配偶者の年収",null,null,null,null,null,null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,"現在、配偶者はいない"]
[null,null,null,null,null,null,null,null,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,"長男"]
[null,null,null,null,"長女"]
[null,null,null,null,"二男"]
[null,null,null,null,"二女"]
[null,null,null,null,"三男"]
[null,null,null,null,"三女"]
[null,null,null,null,"四男"]
[null,null,null,null,"四女"]
[null,null,null,null,"五男"]
[null,null,null,null,"五女"]
[]
[]
[]
[null,null,null,"被保険者が新規に資格取得した"]
[null,null,null,"子が生まれた"]
[null,null,null,"認定対象者が退職した"]
[null,null,null,"雇用保険失業給付の受給が終了した"]
[null,null,null,"認定対象者の収入が基準内に減った"]
[null,null,null,"被保険者と結婚した"]
[null,null,null,"その他"]
[]
[]
[null,null,null,"受給権なし"]
[null,null,null,"受給終了"]
[null,null,null,"受給権あるが受給しない"]
[null,null,null,"受給中"]
[]
[]
[null,null,null,"あり"]
[null,null,null,"なし"]
[]
[]
[null,null,null,"両方の受給権なし"]
[null,null,null,"傷病手当金を受給予定"]
[null,null,null,"傷病手当金を受給中"]
[null,null,null,"障害年金を受給予定"]
[null,null,null,"障害年金を受給中"]
[null,null,null,"両方を受給予定"]
[null,null,null,"両方を受給中"]
[]
[null,null,null,"被保険者が単身赴任のため"]
[null,null,null,"学生の子が通学のため"]
[null,null,null,"その他"]
[]
[]
[null,null,null,"生活費のほとんどを支援"]
[null,null,null,"生活費の一部を支援"]
[null,null,null,"支援なし"]
[]
[]
[null,null,null,"既に被扶養者に認定されている"]
[null,null,null,"離婚のためいない"]
[null,null,null,"死別のためいない"]
[null,null,null,"未婚のためいない"]
[null,null,null,"その他"]
[]
[]
[null,null,null,"既に受給満了のため"]
[null,null,null,"加入期間が不足しているため"]
[null,null,null,"雇用保険に未加入であったため"]
[]
[null,null,null,"なっている"]
[null,null,null,"同時に申請中"]
[null,null,null,"なっていない"]
[]
[null,null,null,"離婚"]
[null,null,null,"死別"]
[null,null,null,"未婚"]
[null,null,null,"その他"]

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