Dependent Certification Check List
Name ofinsured[This is a set with the Dependent Application Record]

Name ofapplicant

Reason for applying for certification(1) Retirement of spouse or child(2) Retirement of parent(3) Retirement to part-time position(4) Reduction in income(5)

Marriage (retirement)(6) Marriage (unemployed, retired several years ago, or working part time)organization (unemployed with no income)(7) End of employment insurance(9) Joining an organization (part-time work)(8) Joining an(10) Other (Reason:）←Cannot be certified if left blank

Check start (Please proceed by checking yes or no.)If any corrections are made to the items herein, please use two lines to cross out the mistake and affix arevision seal where the correction was made.

The insured person is providing the ongoing primary
support of the applicant based on the reasons above

□ No

□ Yes
The applicant is either your parent, grandparent,
spouse (including common-law partners), child,grandchild, or sibling□ No

The applicant is either a sibling of your parent, siblingof your spouse's parent, child of your spouse, or aparent or child of a common-law partner

□ Yes

□ Yes
Living together sharing household
finances

Living together sharing household finances□ No□ No□ No□ Yes□ Yes□ NoThe applicant covers living expenses from yourmonthly remittance and you are the primary source ofsupport□ No

The amount of your remittance is higher than the sum
total of the income of the applicant and the income offamily living with the applicant(Remittance > Income of applicant + Income of familyliving with applicant)□ Yes
A person other than you provides assistance to theapplicant□ Yes□ No□ No

The amount of your remittance is higher than the sum
total of the income of the applicant, the income offamily living with the applicant, and the amount ofadditional assistance(Remittance > Income of applicant + Income of familyliving with applicant + Amount of additionalassistance)□ Yes
The annual income is less than one half of your annual income

□ No

□ No

□ Yes
The income of the applicant (employment and all other income, including all pension money) is less than 1.3 million yen, or 1.8
million yen if age 60 or older or disabled, and the monthly income is less than 108, 334 yen or 150,000 yen for individuals age 60 orolder or individuals receiving a disability pension□ Yes
The applicant is a business operator (soleproprietorship)□ No

The applicant may not be certified in some cases. However,please apply by attaching all the required documents□ Yes

The applicant cannot be certified as a health insurance dependent.

The applicant cannot be certified as a health insurance dependent.

□ Yes

The applicant is a recipient of illness and injury
allowance, birth allowance, or unemployment
insurance benefits(If the allowances or benefits have ended, please check“No”)□ No

The illness and injury allowance orbirth allowance received by theapplicant is a payment less than
3,612 yen (less than 5,000 yen for
individuals age 60 and over) instandard daily compensation□ Yes

The applicant is eligible to receive illness and injury allowance orbirth allowance

□ Yes

□ No

□ Yes

□ No
The applicant is receiving unemployment
benefits from employment insurance

□ No

□ Yes

□ No

The basic daily amount of unemploymentbenefits from employment insurance is lessthan 3,612 yen (less than 5,000 yen for those
aged 60 and over)□ Yes

The applicant is currently extending receipt ofunemployment benefits (in application process) or iscurrently under payment restrictions (in applicationprocess)

□ Yes

□ No
The applicant does not intend toreceive unemployment benefits

□ No

□ Yes

The certification applicant may be certified as a dependent. Please apply by attaching all the required documents*If any corrections are made to the items herein, please use two lines to cross out the mistake and affix a revisionseal where the correction was made.