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["生活状況実態調査書"]
[{"$nulls":7},"※健保記載欄"]
["記号","番号","被保険者氏名",null,"認定対象者氏名",null,null,"標準報酬月額"]
[{"$nulls":7},"千円"]
["※認定対象者につきまして、生活状況の実態をご記入ください。"]
["支出","科目名",null,"世帯平均支出額\n　１ヶ月分(円）","支出","科目名",null,"世帯平均支出額\n　１ヶ月分(円）"]
["食費","飲食費",null,null,"雑費","保健医療費"]
["住居関係費","住居費",null,null,null,"健康保険料・年金保険料等"]
[null,"水道光熱費",null,null,null,"生命保険料・学資保険料等"]
[null,"家具・家事用品費",null,null,null,"教育関係費"]
["税金","住民税",null,null,null,"教育娯楽費"]
[null,"所得税",null,null,null,"交際費"]
[null,"その他税金",null,null,null,"ローン"]
["被服","被服・履物費",null,null,null,"こづかい"]
["雑費","交通費",null,null,null,"仕送り金"]
[null,"通信費",null,null,null,"その他支出"]
["世帯平均支出額合計（ａ）",{"$nulls":6},"円"]
["世帯人数（ｂ）※認定対象者を含む",{"$nulls":6},"人"]
["（ａ）÷（ｂ）",{"$nulls":6},"円"]
["被保険者の負担額　",{"$nulls":6},"円"]
[]
["※生計費費目（例）"]
["住居費",null,"家賃、住居の修繕、畳、建具の購入代、建物火災共済（短期）掛金。庭木の手入れ賃など。"]
["家具・家事用品費",null,"電化製品、家具、食器、カーテン、寝具類等の購入・修理代。"]
["その他税金",null,"自動車税、固定資産税、その他の税金。"]
["被服・履物費",null,"衣類、履物、帽子、カバン、ライター、傘などの購入・修理代。クリーニング代。"]
["交通費",null,"電車・バス・船賃。自動車の購入・修理・ガソリン代、車検費用。任意の自動車共済などの掛金。有料道路通行料。"]
["通信費",null,"はがき、切手、宅配便の料金。固定電話・携帯電話・インターネットのプロバイダ料金。"]
["保健医療費",null,"洗剤、化粧品、売薬、眼鏡等の購入代。理容・理髪代。診察料、薬代、人間ドック代。"]
["教育関係費",null,"教科書、参考書、文房具等の購入代。授業料、受験料、ＰＴＡ会費。通学定期代。学習塾の月謝。"]
["教育娯楽費",null,"テレビ受信料。各種学校、稽古事の月謝・教材費。仕事以外の旅行費。新聞、雑誌、書籍代。ペットの費用。"]
["交際費",null,"婚礼・出産・入学などの祝い、病気・災害見舞い、香典などの贈答金品。中元、歳暮、婚礼、葬儀、法事。等"]
["仕送り金",null,"被保険者が他の家族に対する仕送り額。"]
["※交通費には被保険者の通勤費も含みます。"]
[]
[]
[null,"中部アイティ産業健康保険組合 理事長　殿"]
[{"$nulls":6},"令和　　年　　月　　日"]
[null,"　　当記述書の記載内容は事実と相違ありません。"]
[]
[null,null,"被保険者署名"]
[]
[]
[]
["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）"]