* 2202000*《 Tentative translation of "HIFUYOSHA (IDO) TODOKE / SANGO HIHOKENSHA KANKEI TODOKE" 》 Only for reference: Do not use this English form.

様式コードFormcode

2 2 0 2

Employees' Health Insurance: Report of Dependents (change)
National Pension: Application to Enroll in as Category Ⅲ Insured Persons

For workplaces coveredby Association-managed
EHI

Date of submission : Reiwa era/Y/M

Enter the date when the employer submitted this report to the JPS
Branch Office or Processing Center.

/DWorkplace
code

Employer
提出者情報－I hereby confirmed the worker's and each person's Individual Numbers (or Basic Pension Numbers) here arecorrect.

Address ofworkplace〒― to enter the workplace code and theMake sureinsured person's number of the worker.
Circle "Confirmation" if the employer confirmed that the reported
spouse / dependents are subject to dependent (spouse)deduction under the income tax law. With the employer's
confirmation, you don't need to submit documents to prove
spouse / dependent's income. Yet we need documents to show
non-taxable income.

Name ofworkplace
Employer'sname
Telephone（A. Insured person(2)

Name(6)Year

Date ofenrollment

5. Showa era
7. Heisei era
9. Reiwa era

Date employer received
spouse/dependent report(3)( in KANA characters )（Family name）

Insuredperson's
numberLabour and Social Security Attorney
Name/ address/ contact numberEnter the date when the employer received the report fromthe spouse through the insured person/worker.

）

I, the employer, hereby confirmed that the reported dependents
Circle "Confirmation" at right if
whose income documents are not attached, are subject to dependent
Confirmation
Confirmation the employer confirmed(spouse) deduction under the income tax law.
information.

(1)

Receipt date stampThis form also serves as "Application toEnroll in as Category Ⅲ Insured Persons"under the National Pension system when it
involves with a report on a spouse of an
insured person under the Employees'
Pension Insurance.
In this case, the spouse is the Category Ⅲ
insured person and the worker is Category
Ⅱ insured person under the National
Pension system.

Day (4)MonthSexDay

1. Male2. Female(or Basic Pension Number)

Day (7)(8)

No need to enter address if you give Individual Number in (5).

Address(Annual)
IncomeMonth(5) Individual NumberEnter the insured person's estimated annual income
amount for the next year in (7).
MonthYearYear

5. Showa era
7. Heisei era
9. Reiwa era

Date of birth（First name）

Reiwa era― to prove relationship between the insured person and the spouse if 1) you〒 documents
You don't need to submit
give both persons' Individual Numbers in A.(5), and B.(4), AND 2). the employer confirmed their relationship byKOSEKI TOHON (family registry) or equivalent official documents, and checked the ☑ in B.(15).

Yen

If the employer confirmed the relationship between the worker and reported spouse / dependents by examining official evidence documents such as KOSEKI TOHON (family registry), check the box ☑ in B. (15) or C. (16).
To report that the worker's spouse becomes worker's dependent (i.e. Category Ⅲ insured person), or not dependent, circle "Applicable" or "Not applicable" respectively. Circle "Change" to report any change in reported data.

B. Dependent spouse (Category Ⅲ insured person)(2)

I hereby report regarding a Category Ⅲ Insured Person.

(1)

Reiwa era

NameYearMonthDay

Enter the date when the insured person
submitted this report to the employer.

Year

5. Showa era
7. Heisei era
9. Reiwa era

Date of birthMonthDay(3)
Relationship

1. Husband 2. Wife
3. Common- law husband
4. Common- law wife

(in KANA characters)(4) Individual Number(or Basic Pension Number)(7)〒(Check the box)

―Address

1. Living in samehousehold
2. Different address

If you submit this report form together with the "Application to Enroll in EHI/ EPI", enter same date as A. (6) above inB.(9). If not, enter the date when you become dependent of the insured person.

1.Applicable(9) First day as
dependent (CategoryⅢ)

9.
Reiwa era(13) First day as
not-dependent(Not Category Ⅲ)

9.
Reiwa eraＡ.

2. Notapplicable

3. Change
Fill in (16)~(19)only if you live
abroad or
moved intoJapan.

1. ApplicableYearDayMonth(10)ReasonYearDayMonth(18) First day to be notapplicable for overseas

2. Not applicable special caseYear(14)1. Deceased （Reiwa era/Y /M
2. Divorced
3. Employment / increase in income
Day (17)Month

9.
Reiwa era

Day (19)Month

9.
Reiwa era

/Y/M)

Circle applicable( number in (11). )1. Unemployed
2. Part-time
3. Pension recipient
4. Others

4. Marriage abroad
5. Others ()1. Move into Japan on Reiwa era
2. Others (Reason(20) Income of spouse if not dependent

1. Home 2. Mobile 3. Office 4. Others
Telephone number/D） 4. Reaching age 75
5. Disability assessed
6. Others ()1. Study abroad
2. Accompany worker detached abroad
3. Designated activity

ReasonYear(8)(11)
1. Employment of the insured person
4. Decrease in income
Occupation
2. Marriage
5. Others ()3. Leaving
job applicable reason for becoming the dependent in (10).
CircleReason(16) First day to be
applicable for overseas
special case(in KANA characters)(6) Common
name(5) Foreign nationality
I, the dependent spouse, hereby entrust my spouse (Category Ⅱinsured person), the submission of this report.

(12)(Annual)IncomeYen(15) Enter dependent spouse's estimated income innext one year in (12), including non-taxable
income such as disability pension, survivors
pension and unemployment benefits. For any
Remarksnon-taxable income, submit photocopy ofdocuments to show the paid amount.

/D
Employer confirmed relationship.

Spouse's (annual) income

種別31

□

YenTo report that other person becomes dependent, or not dependent, circle "Applicable" or "Not applicable" respectively. Circle "Change" to report any change in reported data.

(1)

C. Other dependent 1(2) Dateof birth(in KANA characters)（Family name）（First name）

NameYear

5. Showa era
7. Heisei era
9. Reiwa era〒―

2. Different address

9. Reiwa era

3. Change(14)
First day as
not-dependent

9. Reiwa era(1)(in KANA characters)Ａ.

2. Notapplicable

Year

MonthMonth

C. Other dependent 2（First name）（Family name）

Name(6)
Address

1.Applicable
Applicable

Ａ.

2.Not
Not
applicableapplicable

3.Change
ChangeDay (11)

Occupation
YearDay (15)

1. Unemployed
2. Part-time
3. Pension recipientReason

1. Deceased
2. Employment(2) Dateof birth

5. Showa era
7. Heisei era
9. Reiwa eraYear

5. Disability assessed
6. Others (2. Different address(19)First day asdependent(14)
First day as
not-dependent〒DayMonth(3)Day (15)

ReasonSex

2. Female

3. Increase in income
4. Reaching age 75

5. Disability assessed
6. Others (1.海外特例
1.Applicable
要件該当

Overseas
specialcase

Reason1. Move into Japan on Reiwa era
2. Others (Reason2.海外特例
2. Not
要件非該当
applicable(4)
Relationship(8)Reason(9)
Reason(12)

1. Birth
2. Leaving job
3. Decrease in income

1. Biological/adopted child
2. Child other than 1.
3. Parent/adoptive parent
4. Parent-in-law
5. Younger brother/sister/Y/M/D)

4. Living in same household
5. Others□

Yen

6. Older brother/sister
7. Grandparent
8. Great-grandparent
9. Grandchild
10. Others ()1. Study abroad
2. Accompany worker detached abroad
3. Designated activity 4. Marriage abroad
5. Others ()1. Move into Japan on Reiwa era
2. Others ((13)(Annual)income3. Pension recipient
1. Deceased
2. Employment(9)1. Study abroad
2. Accompany worker detached abroad
3. Designated activity 4. Marriage abroad
5. Others ()Employer has confirmed their relationship.

1. Male(7)MonthReason

YenRemarks

If the dependent person lives separately, enter amount of money the insured person
sends to him/herYeareach Monthtime in (16),and enter how many times a year the insured person
Day (11)
1. Unemployedplans
at the bottom. Annual
2. Part-time
9.
Reiwatoerasend money in the declaration columnYear(8)6. Older brother/sister
7. Grandparent
8. Great-grandparent
9. Grandchild
10. Others ()

(16))

―

Occupation

Relationship

1. Biological/adopted child
2. Child other than 1.
3. Parent/adoptive parent
4. Parent-in-law
5. Younger brother/sister(13)(Annual)incomeFill in (7)~(9) only if
you live abroad or
moved into Japan.

9. Reiwa era

2. Notapplicable

(4)

(12)

4. Junior high school student or younger
5. High school/university student（ grade)
6. Others（)

3. Increase in income
4. Reaching age 75

1.Applicable

Overseas
specialcase(5) Individual
Number
1. Living in samehousehold

2. Female(7)
Fill in (7)~(9) only if
you live abroad or
moved into Japan.

(19)First day asdependent

1. MaleSex

1. Living in same
household

1. Applicable(3)(5) IndividualNumber(6)AddressDay

MonthReason

1. Birth
2. Leaving job
3. Decrease in income/YRemarks

Employer has confirmed their relationship.

Use one form to report each for "Applicable", "not applicable" or "Change". You cannot use one form to report them together.
Declaration regarding dependents (Enter comments about your evidence documents if needed.)

I hereby declare the statement herein is true and correct.

Name/D)

4. Living in same household
5. Others(16))/M□