Document code

22 0 2Heisei

Health insurance

YearMonthOfficecode

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

Fill up guide

For use of the Association

Nationalpension

Submit dateOnlyー fill the information of the relatives you want to declare as
theHealthI confirmed that there is no error dependents
in the personal number (basiconpensionnumber)of this form Insurance (Shakai Hoken)

Receiving confirmation/

namefill out the fields C2 and C3 based on the sample/

Important points:
Social insurance (shakai hoken) fieldThis form will be sent to the Shakai hoken office, fill out all the fields in Japanese.
Name andothers
Company
Write the dependents name in Japanese, it is not possible to issue cards with the name written in alphabet.
ownername㊞
Fill out the Furigana field㊞(The cards willtake on) average 1 month to be issued by Shakai Hoken

Phone

Circle when the company owner
Confirmed
has confirmed

Company ownerconfirmation field②

Insuredpersonorganization
number(Furigana)

クルス(Familly name)

Name

Acquisiton
dateyear7.
Heiseiyearyear

⑤

day ④

month60

7.Heisei01 01monthday

1. male 2. female

Gender01 1 2 3 5 813 213

My number㊞

マリア
day ⑦Incomemonth

5. Showa

Birthday(Name)

Heiseidate
Fill out theJapanese year

③マリアクルス⑥Company ownerreceiving

Those whose omitted the attachment of proof of income, we confirm to be dependent

spouse and relatives deductable under the Income Tax Law.
Fill out your namein Japanese①A) InsuredYour enrollment
date issame time its accepted as the " third category
national pension relationship notification", andA) Insured (you) B) Spouse (only if you will declare)
the insured spouse will be converted from theC) Others 1,2 and 3 (children and others) if you do have other dependents
youwish to declare ,Office
third to the secondcategory.

StampEmployer field

When there is a statement concerning theOffice 〒ーspouse in the welfare pension (nenkin), at theaddress
The fields you have to write are highlighted in white. Divided in 3 parts.

Foreign If you filled the ｢My number｣ field, the address is not necessary〒－nationality⑧(Annual)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.
①

Fill out the name and year in JapaneseYear(Furigana)Name(Name)

Monthクルスペドロクルスペドロ

Living together 〒Livingseparate

Address⑨ Date that

became adependent

Confirmation

5.Showayear

My number⑤⑥ Foreign

year

month

day ⑩Reason

02 08 01

⑬ Date that ceased to⑭02

1. Husband 3. Husband(not registered)(Relationship) 2. Wife 4. Wife(not registered)(Furigana)

name⑧ー7.
Reiwa

02

098 7 6 5 43 3 21 0Foreignnationality□day ③ Gendermonth62

7.Heisei④㊞* The submission of the notification concerning the third category insured person relationship is delegated to the spouse (No. 2 insured per⑦

BirthdayDay

StampHeiseiB) Spouse②

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

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((checkof disabilityabove)⑪Occupation)

1. home 2. mobile 3. work 4.others

Phonenumber⑮090-1234-5678

1. Unemployed 4.others
2. Part time ()3. Pensioner⑫

Income(annual)

1,000,000円

monthyear
7.
Are
you enrolling
for thefirst daytimeon Shakai hoken by Techno Service? Notes
bea dependant(No.3
ReasonHeiseiChangeinsured person))⑨ Date - Fill the same date that you will be enrolled⑩Reason - circle 5 “others”⑯
Otherwise
Spouse incomecheck(annual) the back for more info yen
Please fill in if you have a spouse who is not adependant.
Not applicable

Classification31

Fill out the name and year in Japanese

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.
①(Furigana)(Family name)C) Other 1

Name⑦
Confirmation

Not applicable⑪①

Date that becamea
dependant

7.
Reiwa

Birthday⑤ My

アナyearmonthnumberday ⑧02 08 01

Profession

5.Showa
7.Heisei

20yearday ③Gender

month

11 30

⑥123456789100

Address

1. Unemployed
2. Part time
3. Pensioner

4. Elementary･junior high student or under

5. High･college student( grade)

6. Others ()⑫Birthday(Name)

5.Showa
7.Heiseiyear

monthday

Address

number⑦

Date that becamea
dependant

7.
Heisei

Date that ceased to7.

Confirmation

year

month

day ⑧

1. Unemployed

Profession 2. Part time

3. Pensioner

year

month

day ⑫

4. Elementary･junior high student or under ⑨

5. High･college student( grade)

6. Others (Gender⑥⑤ My⑪④

2. Female

1. Child/adopted child 6. Oldersibling
2. 1 Other children 7. GrandparentRelationship 3. Parents/ adoptive parent 8. Great grandparent

1. Same2. Different address(04. Parent-in-law
9. Grandson
5. Sibling
10. Other⑩
1. Birth
4. Living together
Reason 2. Unemployment
5. Othersyen
3. Income decrease ())⑬

You must:
Fill out all the dependents MY NUMBER
Not applicable⑨
Income(Annual)

1. Male1. Death 3.Income increase 5. Certification of disability⑩Reason - circle 5 “others”
Are you enrollingyearfor month
the firstdaytime
Reasonon Shakai hoken by Techno Service?
Notes
2. Employment 4. Became 75 years old 6. Others()⑦ Date - Fill the same date thatyou will be enrolled (check the above)
Otherwise ④
check1.theback childfor 6.moreinfo②③Child/adopted
Oldersibling

Date that ceased to7.
be a dependant Heisei(Furigana)(Familyname)Name②

アナ(Name)

クルス

ChangeC) Other dependent field 3 C) Other dependent field 2クルス)1. Male2. Female

2. 1 Other children 7. Grandparent
Relationship 3. Parents/ adoptive parent 8. Great grandparent

1. Same2. Different address(Income(Annual)

4. Parent-in-law
9. Grandson
5. Sibling
10. Other⑩
4. Living together
Reaso 1. Birth
5. Othersn 2. Employmentyen
3. Income decrease ())⑬

1. Death 3.Income increase 5. Certification of disability

ReasonNotes
Besidesout here, we are only able
to issuethe cards of those that
submitted
their MY NUMBER via the app
be afilling
dependantit Heisei
Change2. Employment 4. Became 75 years old 6. Others()
FASTAPP,orthroughmailontheMY
NUMBER
form.
①②④
1. Child/adopted child 6. Oldersibling(Furigana)
yearmonthday ③Name(Familyname)Birthday(Name)

5.Showa
7.HeiseiGender

1. Male2. Female

Send a complete residence certificate (Jyuminhyo)⑥⑤ My

1. SameAddress
2. Different address(number⑦

Date that becamea

7.

yearmonthday ⑧

1. Unemployed

4. Elementary･junior high student or under ⑨

Income2. 1 Other children 7. Grandparent
Relationship 3. Parents/ adoptive parent 8. Great grandparent

4. Parent-in-law
9. Grandson
5. Sibling
10. Other
4. Living together
Reaso 1. Birth
5. Othersn 2. Employmentyen
3. Income decrease ())⑩

5. High･collegestudent( grade)you wish to declare as dependents.
Part time
It must state:
name, My Number andProfession
the 2.relationshipofeverybody
dependant Full(Annual)
Heisei
3. Pensioner
6. Others ()Checkbesides
theJyuminhyo
on⑬the document guide.
⑫⑪ if you will need to submit other documents
1. Death 3.Income increase 5. Certification of disabilityyear
monthday

Confirmation

Not applicable

ChangeDate that ceased to7.
be a dependant Heisei

Reason2. Employment 4. Became 75 years old 6. Others()

Notes

Need another form, MY NUMBER submission form or more information?
Accessoursupport
Request for support(Please fillin thestaff
case wherethe attachedpage→document can not be submitted.)
https://www.hatarakunavi.net/service/do/tsg_support_top_en* Applicant's "applicable" and "non-applicable (changes)" can not be submitted at the same time. Please submit "applicable", "not applicable", "changes" on separate sheets.

I hereby confirm that the statements are correct

Name

㊞

If you are joining Shakai Hoken for the first time at Techno Service•

ReasonCircle “others”•Date that that became a dependant
Fill the same date that you will be enrolled

Extra reference for Reason and date that became dependent• Retirement (won’t work anymore)
The day after the retirement date
• No longer receiving unemployment insurance (Hello Work)The day after the unemployment benefit payment ends
• Child birth
Birth date
• Marriage
The day you signed the wedding papers at the city hall
• Other reason
Appropriate date depending on the situation