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[]
[null,"健康保険 高齢受給者基準収入額適用申請書"]
[]
[]
[]
[]
[null,"届出年月日",null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,"記号・番号\n（保険証左上に記載）",{"$nulls":10},"－",{"$nulls":6},"事業所名"]
[]
[null,"被保険者氏名",{"$nulls":21},"被保険者\nTEL",null,null,"　　　　　　　（　　　　　　　　　　）"]
[]
[]
[]
[null,"認定対象者","氏名",{"$nulls":17},"生年\n月日",{"$nulls":6},"年",null,null,"月",null,null,"日","続　柄"]
[]
[]
[null,null,"現在所持している高齢受給者証の発効年月日",{"$nulls":22},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,"70歳以上の被保険者・被扶養者の収入申告欄"]
[null,"収入項目",{"$nulls":7},"被保険者氏名",{"$nulls":7},"被扶養者氏名",{"$nulls":7},"被扶養者氏名",{"$nulls":7},"収入に含ま　　　　　　　れないもの"]
[]
[null,"公的年金収入",{"$nulls":31},"・退職金　　　　　　　・障害又は遺族にあ係る年金恩給等　　　　　　　　　　・戦没者等の遺族あに対する特別弔あ慰金　　　　　　　　　・児童手当、児童あ扶養手当　　　　　　・災害弔慰金　　　　　　　　　・健康保険法等にあよる傷病手当金　　　　　　　　　　　　　・雇用保険法によある失業給付等"]
[null,"老齢基礎･老齢厚生･退職共済"]
[null,"老齢･退職年金等",{"$nulls":14},"円",{"$nulls":7},"円",{"$nulls":7},"円"]
[null,"給 与 収 入"]
[null,"（パート収入など含む）",{"$nulls":14},"円",{"$nulls":7},"円",{"$nulls":7},"円"]
[null,"その他の収入"]
[null,"利子･配当･不動産･事業･譲渡"]
[null,"一時･雑収入等",{"$nulls":14},"円",{"$nulls":7},"円",{"$nulls":7},"円"]
[null,"計",{"$nulls":14},"円",{"$nulls":7},"円",{"$nulls":7},"円"]
[null,"合計",{"$nulls":30},"円"]
[null,"上記のとおり収入の額を申告し、関係書類を添えて健康保険高齢受給者基準収入額適用の申請をします。"]
[null,"【 注 意 】"]
[null,"1.","市町村税を課されているか、いないかにかかわらず、70歳以上の被保険者及び被扶養者(65歳以上で老人医療の障害認定を受けている方も含む)それぞれの収入額を公的年金､給与､その他の収入に分けて記入してください｡"]
[null,"2.","収入額はすべてご記入ください。ただし、退職金及び公租公課の対象とならない収入（障害又は遺族に係る年金・恩給等、戦没者等の遺族に対する特別弔慰金、児童手当・児童扶養手当等、災害弔慰金等）は除きます。"]
[null,"3.","収入の欄に記載した金額の証明できる市区町村長の発行する(非)課税証明書、公的年金等源泉徴収票、給与源泉徴収票、確定申告書の写し等の収入額の確認できる書類を添付してください。"]
[null,null,"なお、収入額を確認できる書類を所持してなく、かつ、収入額を証明する書類の発行ができない収入については添付不要です。"]
[]
[null,"事　業　主　証　明　欄"]
[null,"　　　　　　　　","所 在 地"]
[null,"　　　　　　　","事業所名"]
[null,"　　　　　　　　    　　　　　                    　　　　　　　　　　　　　　　　　 印","事業主名"]