Document code

Health insurance

2 0 2Heisei

For use of the AssociationYearMonthNational pension

Dependent person（change) declaration
Insured person notification of relation No. 3

Submit dateOfficecodeーReceiving confirmation

I confirmed that there is no error in the personal number (basic pension number) of this form

Employer field

Officeaddress〒

When there is a statement concerning thespouse in the welfare pension (nenkin), at thesame time its accepted as the " third category
national pension relationship notification", andthe insured spouse will be converted from thethird to the second category.

ーOfficename

Social insurance (shakai hoken) field
Name and othersCompanyowner name㊞(PhoneCompany ownerconfirmation field

Circle when the company owner
Confirmed
has confirmed②A) Insured person
field

①

Insuredpersonorganization
number㊞)③(Furigana)Name(Famillyname)Birthday(Name)㊞⑥Company owner receiving
date

Those whose omitted the attachment of proof of income, we confirm to be dependent
spouse and relatives deductable under the Income Tax Law.

day ⑦Income

5. Showayear

Heiseiyear
day ④month

7.Heiseimonthday

1 male 2 female

Gender⑤My number(Pension number)

Foreign If you filled the ｢My number｣ field, the address is not necessary〒－nationality
円
If your dependant spouse has became a (3rd category insurance dependant) circle "applicable","not applicable" if your dependant is not a dependant anymore, and "change" in case of changes.
Acquisiton
dateB) (No. 3 insured person) spouse field

①year

7.
Heiseimonth⑧(Annual)②

Regarding the 3rd category dependants, it will be declared as written on this statement

HeiseiNameYearMonthBirthdayDayAddressConfirmation

Not app icable⑯

5. Showayear

day ③ Gendermonth

1 Husband 3 Husband(not reg s e ed)(Relationship)

7. Heisei

2. Wife

4. Wife(not registered)④

My number(Furigana)(Name)㊞* The submission of the not fication concerning the third category insured person relationship is delegated to the spouse (No. 2 insured pers⑦

ChangeLiving together 〒Living separateー⑨ Date that became

year

month

day ⑩
Reason⑬ Date that ceased toyear

month

day ⑭Reason7.
a dependant (No. 3Heisei
insured person)
7.
be a dependant (No.3Heisei
insured person)(Pension number)⑤⑥ Foreign

Foreignnationality□⑧

1. Spouse's employment
2. Marriage
3. Leave work
1. Death (Heiseiyear
2. Divorce

4. Income decrease
5. Others(monthday)
4. Became 75 years old 6. Others
3. Employment･ Income increase 5. Certification of disabi ity (1 home 2 mobile

Phonenumber4 others）

1 Unemployed
Profession 2 Part time (3 Pensioner)

3 work(⑪4 others ⑫Income)(annua )円⑮Classification31Notes)
yenSpouse income (annual)

Please fill in if you have a spouse who is not a dependant.

(Furigana)

name

If your dependant other than spouse has became a (3rd category insurance dependant) circle "applicable","not applicable" if your dependant is not a dependant anymore, and "change" in case of changes.

C) Other dependent field 1①NameC) Other dependent field 2②(Furigana)(Family name)Birthday(Name)

5. Showa
7. Heisei

year

day ③
Gender

month

⑤ My

⑥Address

number⑦
Confirmation

Not applicable

Change①Name

Date that became adependant

7.
Heisei⑪

Date that ceased to 7.
be a dependant Heisei

yearmonthday ⑧
Professionyearmonthday⑫

Reason1. Death

4. Elementary･junior high student or under

5. High･college student(grade)

6. Others ()3.Income increase

Birthday(Name)

5. Showa
7. Heisei

year⑦

Not applicable

ChangeName

Date that became adependant

7.
Heisei⑪

Date that ceased to 7.
be a dependant Heisei

year

month

day ⑧
Professionyearmonthday⑫day ③
Gendermonth

Reason5. High･college student(grade)

6. Others ()Birthday(Name)

5. Showa
7. Heisei

year

ConfirmationNot applicable

Change⑪

Date that became adependant

7.
Heisei

Date that ceased to 7.
be a dependant Heisei

year

month

Professionyearmonthday⑫

Reasonday ③
GendermonthAddress

1. Death

4. Elementary･junior high student or under

5. High･college student(grade)

6. Others ()3.Income increase

5. Certification of disabi ity

2. Employment 4. Became 75 years old 6. Others(④2. Female

1. Child/adopted child 6. Older sibling
2. 1 Other children
7. Grandparent

Relationship 3. Parents/ adoptive parent

1. Same2. Different address (⑨Income(Annual)⑥

1. Unemployed
2. Part time
3. Pensioner

9. Grandson
10. Other
4. Living together
5. Others()

4. Parent-in-law
5. Sibling⑩
1. BirthReaso
2. Employmentnyen
3. Income decrease)

8. Great grandparent

9. Grandson
10. Other
4. Living together
5. Others
()

Notes

numberday ⑧

8. Great grandparent)⑤ My⑦

1. Male⑬

5. Certification of disabi ity

2. Employment 4. Became 75 years old 6. Others(②(Furigana)(Family name)

4. Elementary･junior high student or under

3.Income increase

4. Parent-in-law
5. Sibling⑩
1. BirthReaso
2. Employmentnyen
3. Income decrease)

NotesAddress

1. Death

1. Child/adopted child 6. Older sibling
2. 1 Other children
7. Grandparent

Relationship 3. Parents/ adoptive parent

1. Same2. Different address (⑨Income(Annual)⑥

1. Unemployed
2. Part time
3. Pensioner④

2. Female)⑤ My

Confirmation

1. Male⑬

5. Certification of disabi ity

2. Employment 4. Became 75 years old 6. Others(②(Furigana)(Family name)

1. Unemployed
2. Part time
3. Pensioner

number①C) Other dependent field 32⑨
Income(Annual)⑬

1. Male④

2. Female

1. Child/adopted child 6. Older sibling
2. 1 Other children
7. Grandparent

Relationship 3. Parents/ adoptive parent

1. Same2. Different address (4. Parent-in-law
5. Sibling⑩
1. BirthReaso
2. Employmentnyen
3. Income decrease)

8. Great grandparent

9. Grandson
10. Other
4. Living together
5. Others()

Notes)* Applicant's "applicable" and "non-applicable (changes)" can not be submitted at the same time. Please submit "applicable", "not applicable", "changes" on separate sheets.
Request for support (Please fill in the case where the attached document can not be submitted.)

I hereby confirm that the statements are correct

Name㊞