3.国民健康保険 加入書類記入方法 How to fill in the National Health Insurance“KOKUMIN-KENKO-HOKEN” application form.

日本に入国した日
Date of arrival in Japan
日本での住所（漢字でかく） *住所がすでに印刷されている場合は、部屋番号のみ追記する。
Your address in Japan (Write it in Japanese.) *If the address is already printed on the form, just add
your room number after that.

電話番号 Phone number
持っていない場合は空けておく。
If you don't have a phone, leave it blank.

MMYYYYDDYour name in all capital letters asshown in your residence card.

出身国名を書く（漢字orカタカナで） Your home country (Write it in Japanese.)

LAST, FIRST & MIDDLE name in katakanaYour name in all capital letters asshown in your residence card.

YYYY MMDD

本人

Circle your gender
Male: 男
Female: 女「本人」と書く Write "本人".
( "本人" means “myself". )在留カードに表示されているとおり名前を書く。
アルファベットの場合は、すべて大文字で書く。
Your name in all capital letters as shown in yourresidence card.

(1) LAST name(2) FIRST & MIDDLE name
漢字orアルファベットで書く*名前が長い場合は姓と名を区切る線を無視して書いてください。
Write it in kanji or alphabet*If your name is long, you canwrite over the section line.

生年月日 Date of birth
YYYY: 4-digit year
MM: 2-digit monthDD: 2-digit daye.g. 2001.04.28※書き間違えた場合は二重線で消し 、余白に書きなおす。
※If you made a mistake in writing, you should cross it out
and write the correct one in blank spaces.
e.g.

Doshashashi*記入不要 Sections shaded in grey need not be filled inWhen your name is more than 16 letters in the English alphabet,you need to cut it short, and submit this form.

Declaration form for reporting yourincome of the previous year in Japan*This form is only available for national health insurance.

Your name can be shown in the health insurance card either inthe English alphabet including spaces or katakana within 16letters.

You are required to submit this form to have your annual
premiums of national health insurance determined
Date

YYYYMMDD

Application form for your abbreviated name to be registered with the
National Health Insurance System.

Your address in Kyoto city

DateYour name in all capital letters as shown in your residence card.

YY

Phone number
電話番号=Phone number
持っていない場合は空けておく。
If you don't have a phone, leave it blank.

Your name in all capitalletters as shown in yourresidence card.

生年月日=Your date of birth

YYYY.MM.DDMMDDThis "YY" should be filled in as Japaneseimperial year “Reiwa”.

Your name in all capital letters as shown in your residence card.
昨年、日本で所得がある場合は「営業」「その他」「給与」「年金」を選択してチェックする。また、その他必要な情報を記載する。
Only in case you had any income in Japan last year, select the type ofyour income: “営業 (self-employed)”, “その他 (others)”, “給与(salary)”, “年金 (pension)”, put a tick in the box and fill in otherrequired information.

電話番号。 持っていない場合は空けておく。
Your phone number. If you don't have, please leave it blank.
Regarding your name to be registered with thenational health insurance system,

本人
続柄 = Relationship with theapplicant「本人」と書く Write "本人".
"本人" means “myself".
(1)昨年、日本で所得が無ければ「無収入」にチェックする。
If you had no income in Japan last year, checkthe box of "無収入".
"無収入" means “no income"Check the second box: “my real name (in theEnglish alphabet) with some parts omitted”(2)昨年も日本で住民登録をしており、学生だった場合は、学生にチェックする。
If you are a student, checkthe box of "学生".
"学生" means “student"*記入不要 Sections shaded in grey need not be filled in(3)昨年は日本で住民登録しておらず、今年初めて来日した人は、その他に☑し、YYYY年MM月DD日入国と記入する。
If you have not yet registered as aresident in Japan last year and it isyour first time to come to Japan thisyear, check the box of “その他(others)“, and fill in the arrival dateas ”YYYY年MM月DD日 入国 (the dateof arrival in Japan)".

あなたが希望する16文字以内の名前
Your preferred name (the shortened original name) within 16 letters

記入不要

Leave it blank