List of Documents Required for Dependent Authorization: List B(for persons to whom List A does not apply)

Documents required

Dependent (Change) Notice for Health Insurance System (two pages: original and duplicate): Print thisform from the IBM Japan Health Insurance Association website*Only page 1 is required for Voluntarily and Continuously Insured Persons or those in the Special-Case
Retired Persons Medical Care System○ ○ ○ ○ ○ ○

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Dependent Status Notice (not required upon birth of a child): Print this form from the IBM Japan Health
Insurance Association website.

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Most recent certificate of income/taxation (tax exempt) certificate issued by the local government office

Certificate of Loss of Eligibility for Health Insurance (original)/National Health Insurance card (copy)○ ○ ○ ○ ○ ○

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Other required documentation
Documentation of livelihood relationship

Former employees
Any of the following: separation slips I and II (copies), notice of loss of eligibility for employment insurance(not receiving employment (copy), and retirement certificate
insurance benefits)Former employees(receiving employment
insurance benefits)

Certificate of eligibility for employment insurance benefits (copy)

Current employees

Payslips (copies)/certificate of anticipated income amount○ ○ ○ ○ ○ ○○ ○ ○ ○ ○ ○Persons filing income tax
returns for personal
business income, realestate income, dividend
income, etc.

Details of revenues and expenditures/blue return final settlement report/details of expenses (for submittal
to the Health Insurance Association)*Not required from those earning only dividend income, salary income, or pension incomeNotice of discontinuation of personal business (copy)

Pension recipients

Most recent notice of pension remittance (copy)*Public pension (old age, survivors’, disability), corporate pension, personal pension, etc.
Copies of documentation of remittance of allowance clearly indicating the remitter and recipient ofremittance and remittance amount (e.g., bank remittance, cash registered mail)Certified copy of certificate of residence (for all household members)

Documentation of family
relation, cohabitation with
Official copy (extract) of family register, original source of reestablished family register
insured person, non-Japanesecitizenship, etc.
Certificate of receipt of marriage registration/notification of adoption
Persons with disabilities

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Copy of details of revenues and expenditures/blue return final settlement reportsubmitted to the tax office
If neither is available, submit the Health Insurance Association’s expense details form.

Physical disability certificate (copy)○○○ ○ ○ ○ ○ ○

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See the Dependent Status Notice.

Copies of payslips must be submitted for every pay period within the most recent
three months. Otherwise, the certificate of anticipated income amount (for the periodof one year after the date of certification) must bear the employer’s seal.
If the amount of income decreases due to an amendment of the contract, submit theamended employment contract (notice of employment conditions) or other equivalent
document.

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The certificate of income is used to check for any income (with the amountsindicated) other than salary.
A certificate of income and withholding tax issued by the employer or taxation
certificate issued by a tax office is not acceptable.

○○ ○ ○ ○ ○ ○△ △ △ △ △ ○If you name a child as a dependent and both spouses work, enter the income
amounts for both spouses under section ⑧, “Annual income of husband & wife,
respectively when both are working,” on the Dependent (Change) Notice for Health
Insurance System (no certifying documents are required).
*In principle, the family member will be a dependent of the spouse who earns thehigher income.

If a family member plans to receive 1.3 million yen/year or more from employment
insurance (unemployment insurance) after leaving employment (1.8 million yen/year
or more if aged 60 or above), he or she may not be certified as a dependent while
receiving such benefits (he or she may be certified as a dependent for only the periodof restricted benefits).
If a certificate of eligibility for employment insurance benefits is unavailable at thetime the application is submitted, submit copies of separation slips I and II assubstitute.
Submit the certificate of eligibility for employment insurance benefits as soon as you
receive it.

Income tax return (copy)

Persons who havediscontinued personal
businesses

Persons living apart fromthe insured person○NotesUncles
Aunts

Parents-in-law

Nephews,
niecesGrandparents

Grandchildren

Siblings

Children

Parents

Documents to submit/attach

SpousePersons required toPersons who need notcohabit with the insured cohabit with theinsured person
person○Also applies to nontaxable income, including survivors’ pension and disability pension.
Includes all benefits received in pension form, including corporate and personalpensions.
Submit documentation of the monthly remittance of allowance for the most recent
three months, such as copies of bank remittance notices.
*Not required in cases of unaccompanied job posting○ ○ ○ ○ ○ ○△ △ △ △ △ △○○○△ △ △ △ △ △△△△△ △ △ △ △ △△△△△ △ △ △ △ △△△△For non-Japanese persons, the document must indicate the duration of stay (at leastone year).
For adoptive parents or children, submit an official copy (extract) of the family
register or notification of adoption; for a common-law spouse, submit a certificate orresidence indicating “wife (not registered)” and “husband (not registered)” and official
copies of the family registers for both spouses.

○: Submission required in all cases△: Attachment required for the persons in question

Note 1: Depending on dependent status, additional documents may be required.
Note 2: Submit original documents if “copy” is not specified.
Note 3: Make sure the document submitted was issued within the past three months when submitting any of the following documents: official copy (extract) of family register, certificate of residence, certificate of income (taxation/tax
exempt certificate).