本人目前無其他專職工作，且受領 貴單位之（兼職）薪資所得，未達中央勞工主管機關公告之基本工資（目前為19,047元），依全民健康保險扣取及繳納補充保險費辦法第4條第3項第7款及行政院衛生署102年1月24日衛署健保字第1020061077號函釋規定，請 貴單位免扣取本人補充保險費，謹提具下列證件，以資證明。如有不實，願依全民健康保險法暨相關法律規定處理，特此聲明。
另日後如有其他校外之專職工作，將主動洽人事室修改聲明。
o最近一學期之學校註冊單
o蓋有註冊章之學生證
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