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[null,"様式コード",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険",null,null,null,null,null,null,null,null,null,null,null,null,null,"被 扶 養 者 ( 異 動 ) 届"]
[null,2,null,2,null,0,null,null,2]
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[]
[null,"令和",null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日提出"]
[null,null,null,null,null,null,null,"事業所\n整理記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"－"]
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[null,"提出者情報",null,null,null,null,null,null,null,null,null,null,"届出記入の個人番号（基礎年金番号）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,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"]
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[null,null,null,null,null,null,null,"事業所\n所在地",null,null,null,null,"〒",null,"721-8555"]
[null,null,null,null,null,null,null,null,null,null,null,null,"福山市東深津町四丁目２０番１号"]
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[]
[]
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[null,null,null,null,null,null,null,"事業所\n名 　称",null,null,null,null,"福山通運株式会社"]
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[]
[]
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[null,null,null,null,null,null,null,"事業主\n氏　 名"]
[null,null,null,null,null,null,null,null,null,null,null,null,"代表取締役　小丸　成洋",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"店所コード"]
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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"店所名"]
[null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,"084",null,null,null,null,"（",null,"924",null,null,null,null,null,null,null,null,"）",null,"2000"]
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[null,null,null,null,null,null,null,"事業主\n確認欄",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主等受付年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日"]
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[]
[null,null,null,null,null,null,null,"①",null,null,null,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,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,"5. 昭和\n7. 平成\n9. 令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"④",null,null,"1.男   2.女"]
[null,null,null,null,null,null,null,"被保険者整理番号",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,"生年月日",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,"性別"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名"]
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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,null,null,null,null,null,null,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号\n（基礎年金番号）"]
[]
[]
[null,null,null,null,null,null,null,"⑥",null,null,null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"⑦",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,null,"⑧",null,null,null,null,null,null,null,null,null,"個人番号を記入した場合は、住所記入は不要です。"]
[null,null,null,null,null,null,null,"取得\n年月日",null,null,null,null,null,null,null,null,"",null,"",null,null,"",null,null,"",null,null,"",null,null,"",null,null,"収入\n（年収）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
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[]
[]
[null,"配偶者が被扶養者（第3号被保険者）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」、変更の場合は「変更」を○で囲んでください。"]
[]
[null,null,null,null,null,null,null,"①",null,null,null,null,"第３号被保険者に関し、この届書記載のとおり届出します。",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,"②",null,null,null,null,null,null,null,null,null,"5. 昭和\n7. 平成\n9. 令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"③",null,null,"1.夫　3.夫（未届）　\n2.妻　4.妻（未届）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"l"]
[null,null,null,null,null,null,null,"氏名\n",null,null,null,null,"令和　",null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,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,"生年月日",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,"性別\n（続柄）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"　（ﾌﾘｶﾞﾅ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号\n（基礎年金番号）"]
[]
[]
[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,null,null,null,null,null,null,null,null,"⑤",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑥"]
[null,null,null,null,null,null,null,null,null,null,null,null,"※第３号被保険者関係届の提出は配偶者（第２号被保険者）に委任します",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,"外国籍",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"外国人\n通称名"]
[]
[null,null,null,null,null,null,null,"⑦",null,null,null,null,"同居\n・\n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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑧",null,null,null,null,null,"1.自宅 　2.携帯　 3.勤務先 　4.その他"]
[null,null,null,null,null,null,null,"住所\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話\n番号"]
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[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,"　9. \n　令和",null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"⑩",null,null,null,null,null,"　　1. 配偶者の就職　　　4. 収入減少\n　　2. 婚姻　　　　　　　　　5. その他\n　　3. 離職　　　　　　　　　 （                       ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑪",null,null,null,null,null,"　1.無職　　4.その他\n　2.パート　（　　　　）\n　3.年金受給者",null,null,null,null,null,null,null,null,"⑫",null,null,null,null,null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\n（第3号被保険者）\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"収入\n（年収）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑬",null,null,null,null,null,"　9.\n　令和",null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"⑭",null,null,null,null,null,"　　1. 死亡 （令和　　　年　　　月　　　日）\n　　2. 離婚                   4.75歳到達　　   6.その他 \n    3. 就職・収入増加　   5.障害認定　　　　（　　      　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"発行が必要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"種別\n３１"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\n（第3号被保険者）でなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[null,null,null,null,null,null,null,"⑯　被扶養者でない配偶者を有するとき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,"配偶者の収入（年収）",null,null,null,null,null,null,null,null,null,null,null,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,"配偶者以外の方が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」、変更の場合は「変更」を○で囲んでください。"]
[]
[]
[]
[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,"②",null,"生年月日",null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,"③",null,null,null,"1.男　　2.女",null,null,null,null,null,null,null,"④",null,null,null,"　1. 実子・養子\n　2. 1以外の子\n　3. 父母・養父母　\n　4. 義父母　\n　5. 弟妹　　　　　　　",null,null,null,null,null,null,null,"6. 兄姉\n7. 祖父母\n8. 曽祖父母\n9. 孫\n10. その他"]
[]
[null,null,null,null,null,null,null,"氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,"個人番号",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,"⑥",null,null,null," 1.同居\n 2.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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑦",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑧",null,null,null,null," 1. 無職\n 2. パート\n 3. 年金受給者",null,null,null,null,null,null,null,null,null,null,"4. 小・中学生以下\n5. 高・大学生（　　年生）\n6. その他（　　　　　　　 ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,null,null,null,null,null,"円","⑩",null,null,null,"　 1. 出生\n 　2. 離職\n 　3. 収入減",null,null,null,null,null,"　　4. 同居\n　　5. その他\n　　（　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,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\n（年収）",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,"⑪",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑫",null,null,null,null," 1. 死亡\n 2. 就職",null,null,null,null,"3. 収入増加\n4. 75歳到達",null,null,null,null,null,null,null,"5. 障害認定\n6. その他（　 　　　　）",null,null,null,null,null,null,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,"発行が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nでなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[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,"②",null,"生年月日",null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,"③",null,null,null,"1.男　　2.女",null,null,null,null,null,null,null,"④",null,null,null,"　1. 実子・養子\n　2. 1以外の子\n　3. 父母・養父母　\n　4. 義父母　\n　5. 弟妹　　　　　　　",null,null,null,null,null,null,null,"6. 兄姉\n7. 祖父母\n8. 曽祖父母\n9. 孫\n10. その他"]
[]
[null,null,null,null,null,null,null,"氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,"個人番号",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,"⑥",null,null,null," 1.同居\n 2.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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑦",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑧",null,null,null,null," 1. 無職\n 2. パート\n 3. 年金受給者",null,null,null,null,null,null,null,null,null,null,"4. 小・中学生以下\n5. 高・大学生（　　年生）\n6. その他（　　　　　　　 ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,null,null,null,null,null,"円","⑩",null,null,null,"　 1. 出生\n 　2. 離職\n 　3. 収入減",null,null,null,null,null,"　　4. 同居\n　　5. その他\n　　（　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,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\n（年収）",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,"⑪",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑫",null,null,null,null," 1. 死亡\n 2. 就職",null,null,null,null,"3. 収入増加\n4. 75歳到達",null,null,null,null,null,null,null,"5. 障害認定\n6. その他（　 　　　　）",null,null,null,null,null,null,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,"発行が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nでなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[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,"②",null,"生年月日",null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,"③",null,null,null,"1.男　　2.女",null,null,null,null,null,null,null,"④",null,null,null,"　1. 実子・養子\n　2. 1以外の子\n　3. 父母・養父母　\n　4. 義父母　\n　5. 弟妹　　　　　　　",null,null,null,null,null,null,null,"6. 兄姉\n7. 祖父母\n8. 曽祖父母\n9. 孫\n10. その他"]
[]
[null,null,null,null,null,null,null,"氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,"個人番号",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,"⑥",null,null,null," 1.同居\n 2.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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑦",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑧",null,null,null,null," 1. 無職\n 2. パート\n 3. 年金受給者",null,null,null,null,null,null,null,null,null,null,"4. 小・中学生以下\n5. 高・大学生（　　年生）\n6. その他（　　　　　　　 ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,null,null,null,null,null,"円","⑩",null,null,null,"　 1. 出生\n 　2. 離職\n 　3. 収入減",null,null,null,null,null,"　　4. 同居\n　　5. その他\n　　（　　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,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\n（年収）",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,"⑪",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑫",null,null,null,null," 1. 死亡\n 2. 就職",null,null,null,null,"3. 収入増加\n4. 75歳到達",null,null,null,null,null,null,null,"5. 障害認定\n6. その他（　　　　　　）",null,null,null,null,null,null,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,"発行が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nでなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[null,null,"※被扶養者の「該当」と「非該当（変更）」は同時に提出できません。「該当」、「非該当」、「変更」はそれぞれ別の用紙で提出してください。"]

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[null,"様式コード",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険",null,null,null,null,null,null,null,null,null,null,null,null,null,"被 扶 養 者 ( 異 動 ) 届"]
[null,2,null,2,null,0,null,null,2]
[]
[]
[null,"令和",null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日提出"]
[null,null,null,null,null,null,null,"事業所\n整理記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"－"]
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[null,"提出者情報",null,null,null,null,null,null,null,null,null,null,"届出記入の個人番号（基礎年金番号）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,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"]
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[null,null,null,null,null,null,null,"事業所\n所在地",null,null,null,null,"〒",null,"721-8555"]
[null,null,null,null,null,null,null,null,null,null,null,null,"福山市東深津町四丁目２０番１号"]
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[]
[]
[]
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[null,null,null,null,null,null,null,"事業所\n名 　称",null,null,null,null,"福山通運株式会社"]
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[]
[]
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[null,null,null,null,null,null,null,"事業主\n氏　 名"]
[null,null,null,null,null,null,null,null,null,null,null,null,"代表取締役　小丸　成洋",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"店所コード"]
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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"店所名"]
[null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,"084",null,null,null,null,"（",null,"924",null,null,null,null,null,null,null,null,"）",null,"2000"]
[]
[null,null,null,null,null,null,null,"事業主\n確認欄",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業主等受付年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日"]
[]
[]
[null,null,null,null,null,null,null,"①",null,null,null,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,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,"5. 昭和\n7. 平成\n9. 令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"④",null,null,"1.男   2.女"]
[null,null,null,null,null,null,null,"被保険者整理番号",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,"生年月日",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,"性別"]
[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,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,null,null,null,null,null,null,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号\n（基礎年金番号）"]
[]
[]
[null,null,null,null,null,null,null,"⑥",null,null,null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"⑦",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,null,"⑧",null,null,null,null,null,null,null,null,null,"個人番号を記入した場合は、住所記入は不要です。"]
[null,null,null,null,null,null,null,"取得\n年月日",null,null,null,null,null,null,null,null,"",null,"",null,null,"",null,null,"",null,null,"",null,null,"",null,null,"収入\n（年収）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
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[]
[]
[null,"配偶者が被扶養者（第3号被保険者）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」、変更の場合は「変更」を○で囲んでください。"]
[]
[null,null,null,null,null,null,null,"①",null,null,null,null,"第３号被保険者に関し、この届書記載のとおり届出します。",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,"②",null,null,null,null,null,null,null,null,null,"5. 昭和\n7. 平成\n9. 令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"③",null,null,"1.夫　3.夫（未届）　\n2.妻　4.妻（未届）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"l"]
[null,null,null,null,null,null,null,"氏名\n",null,null,null,null,"令和　",null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,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,"生年月日",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,"性別\n（続柄）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"　（ﾌﾘｶﾞﾅ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号\n（基礎年金番号）"]
[]
[]
[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,null,null,null,null,null,null,null,null,"⑤",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑥"]
[null,null,null,null,null,null,null,null,null,null,null,null,"※第３号被保険者関係届の提出は配偶者（第２号被保険者）に委任します",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,"外国籍",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"外国人\n通称名"]
[]
[null,null,null,null,null,null,null,"⑦",null,null,null,null,"同居\n・\n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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑧",null,null,null,null,null,"1.自宅 　2.携帯　 3.勤務先 　4.その他"]
[null,null,null,null,null,null,null,"住所\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話\n番号"]
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[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,"　9. \n　令和",null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"⑩",null,null,null,null,null,"　　1. 配偶者の就職　　　4. 収入減少\n　　2. 婚姻　　　　　　　　　5. その他\n　　3. 離職　　　　　　　　　 （                       ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑪",null,null,null,null,null,"　1.無職　　4.その他\n　2.パート　（　　　　）\n　3.年金受給者",null,null,null,null,null,null,null,null,"⑫",null,null,null,null,null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\n（第3号被保険者）\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"収入\n（年収）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑬",null,null,null,null,null,"　9.\n　令和",null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"⑭",null,null,null,null,null,"　　1. 死亡 （令和　　　年　　　月　　　日）\n　　2. 離婚                   4.75歳到達　　   6.その他 \n    3. 就職・収入増加　   5.障害認定　　　　（　　      　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"発行が必要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"種別\n３１"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\n（第3号被保険者）でなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[null,null,null,null,null,null,null,"⑯　被扶養者でない配偶者を有するとき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,"配偶者の収入（年収）",null,null,null,null,null,null,null,null,null,null,null,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,"配偶者以外の方が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」、変更の場合は「変更」を○で囲んでください。"]
[]
[]
[]
[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,"②",null,"生年月日",null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,"③",null,null,null,"1.男　　2.女",null,null,null,null,null,null,null,"④",null,null,null,"　1. 実子・養子\n　2. 1以外の子\n　3. 父母・養父母　\n　4. 義父母　\n　5. 弟妹　　　　　　　",null,null,null,null,null,null,null,"6. 兄姉\n7. 祖父母\n8. 曽祖父母\n9. 孫\n10. その他"]
[]
[null,null,null,null,null,null,null,"氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,"個人番号",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,"⑥",null,null,null," 1.同居\n 2.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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑦",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑧",null,null,null,null," 1. 無職\n 2. パート\n 3. 年金受給者",null,null,null,null,null,null,null,null,null,null,"4. 小・中学生以下\n5. 高・大学生（　　年生）\n6. その他（　　　　　　　 ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,null,null,null,null,null,"円","⑩",null,null,null,"　 1. 出生\n 　2. 離職\n 　3. 収入減",null,null,null,null,null,"　　4. 同居\n　　5. その他\n　　（　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,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\n（年収）",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,"⑪",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑫",null,null,null,null," 1. 死亡\n 2. 就職",null,null,null,null,"3. 収入増加\n4. 75歳到達",null,null,null,null,null,null,null,"5. 障害認定\n6. その他（　 　　　　）",null,null,null,null,null,null,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,"発行が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nでなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[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,"②",null,"生年月日",null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,"③",null,null,null,"1.男　　2.女",null,null,null,null,null,null,null,"④",null,null,null,"　1. 実子・養子\n　2. 1以外の子\n　3. 父母・養父母　\n　4. 義父母　\n　5. 弟妹　　　　　　　",null,null,null,null,null,null,null,"6. 兄姉\n7. 祖父母\n8. 曽祖父母\n9. 孫\n10. その他"]
[]
[null,null,null,null,null,null,null,"氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,"個人番号",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,"⑥",null,null,null," 1.同居\n 2.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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑦",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑧",null,null,null,null," 1. 無職\n 2. パート\n 3. 年金受給者",null,null,null,null,null,null,null,null,null,null,"4. 小・中学生以下\n5. 高・大学生（　　年生）\n6. その他（　　　　　　　 ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,null,null,null,null,null,"円","⑩",null,null,null,"　 1. 出生\n 　2. 離職\n 　3. 収入減",null,null,null,null,null,"　　4. 同居\n　　5. その他\n　　（　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,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\n（年収）",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,"⑪",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑫",null,null,null,null," 1. 死亡\n 2. 就職",null,null,null,null,"3. 収入増加\n4. 75歳到達",null,null,null,null,null,null,null,"5. 障害認定\n6. その他（　 　　　　）",null,null,null,null,null,null,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,"発行が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nでなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[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,"②",null,"生年月日",null,null,"5.昭和\n7.平成\n9.令和",null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,"③",null,null,null,"1.男　　2.女",null,null,null,null,null,null,null,"④",null,null,null,"　1. 実子・養子\n　2. 1以外の子\n　3. 父母・養父母　\n　4. 義父母　\n　5. 弟妹　　　　　　　",null,null,null,null,null,null,null,"6. 兄姉\n7. 祖父母\n8. 曽祖父母\n9. 孫\n10. その他"]
[]
[null,null,null,null,null,null,null,"氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑤",null,"個人番号",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,"⑥",null,null,null," 1.同居\n 2.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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"⑦",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑧",null,null,null,null," 1. 無職\n 2. パート\n 3. 年金受給者",null,null,null,null,null,null,null,null,null,null,"4. 小・中学生以下\n5. 高・大学生（　　年生）\n6. その他（　　　　　　　 ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑨",null,null,null,null,null,null,null,null,null,null,"円","⑩",null,null,null,"　 1. 出生\n 　2. 離職\n 　3. 収入減",null,null,null,null,null,"　　4. 同居\n　　5. その他\n　　（　　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nになった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職業",null,null,null,null,null,null,null,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\n（年収）",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,"⑪",null,null,null,null,null,"9. 令和",null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"⑫",null,null,null,null," 1. 死亡\n 2. 就職",null,null,null,null,"3. 収入増加\n4. 75歳到達",null,null,null,null,null,null,null,"5. 障害認定\n6. その他（　　　　　　）",null,null,null,null,null,null,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,"発行が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被扶養者\nでなくなった日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"理由\n"]
[]
[]
[]
[null,null,"※被扶養者の「該当」と「非該当（変更）」は同時に提出できません。「該当」、「非該当」、「変更」はそれぞれ別の用紙で提出してください。"]