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["扶養申請申立書"]
[]
[]
["記号",{"$nulls":5},"番号",{"$nulls":6},"被保険者氏名"]
[]
[]
["認定対象者氏名",{"$nulls":8},"住　　　　　　　　所　（別居の場合）"]
[{"$nulls":9},"〒"]
[]
[]
["（１）　届出の認定対象者を、私が扶養しなければならない理由を下記のとおり申し立てます。"]
[]
["１．","私が扶養しなければならない理由"]
{"$rows_empty":10}
["２．","認定対象者との生活実態",{"$nulls":8},"（該当項目にをつけてください。）"]
[null,null,"□","同居により家計を共にしている。"]
[null,null,"□","別居している。",{"$nulls":4},"（二世帯住宅、同一敷地内の別棟に居住している場合を含む。）"]
[]
[]
["（２）　認定対象者に対する(注)あなた以外の扶養義務者の状況"]
["認定対象者に\n対する続柄",{"$nulls":4},"氏　　名",{"$nulls":6},"同居・別居",null,null,null,"職　業",null,null,null,"年　収(円)",{"$nulls":5},"認定対象者への\n年間援助額(円)"]
[]
[{"$nulls":12},"同 ・ 別"]
[{"$nulls":12},"同 ・ 別"]
[{"$nulls":12},"同 ・ 別"]
["(注)",null,"あなた以外の扶養義務者とは"]
[null,null,"例：①母を申請の場合→父（母の配偶者）②父母を申請の場合→あなたの兄弟姉妹"]
[null,null,"　　③兄弟姉妹を申請の場合→認定対象者の父母及びあなた以外の兄弟姉妹"]
[]
[]
[null,null,null,"中部アイティ産業健康保険組合 理事長　　殿"]
[{"$nulls":19},"令和",null,null,"年",null,"月",null,"日"]
[]
[{"$nulls":5},"上記に記載の内容は事実と相違ありません。"]
[]
[{"$nulls":5},"被保険者署名"]
[]
[]
[null,"被保険者が虚偽の申請により家族の扶養認定を受けたことが判明した場合は、被扶養者の"]
[null,"資格は遡って取り消され、当該期間にわたって発生した医療費の全額及びその他給付金を"]
[null,"過去に遡及し返還しなくてはならない。（健康保険法第５８条による）"]