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["別紙第36"]
[]
[{"$nulls":5},"長期家族介護者援護金支給申請書"]
[]
[{"$nulls":15},"申 請 年 月 日",{"$nulls":5},"令和",null,null,null,"年",null,"月",null,"日"]
["（実施機関の長の官職氏名）",{"$nulls":14},"申請者の住所"]
[]
[]
[{"$nulls":13},"殿"]
[{"$nulls":15},"氏　　　　  名"]
[null,"下記の長期家族介護者援護金の支給を申請します。",{"$nulls":13},"生  年  月  日",{"$nulls":9},"年",null,null,"月",null,"日"]
[{"$nulls":15},"死亡した要介護年金受給権者との続柄"]
["１\n　死亡した\n　要介護年\n　金受給権\n　者に関す\n　る事項",null,null,null,"氏　　　名",{"$nulls":10},"死亡年月日",{"$nulls":6},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":4},"年　金　の　種　類",{"$nulls":7},"□","傷病補償年金（第",{"$nulls":6},"級）",null,null,"年金証書の番号"]
[{"$nulls":4},"・　受　給　期　間",{"$nulls":7},"□","障害補償年金（第",{"$nulls":6},"級）",{"$nulls":4},"第",null,null,null,"号"]
[]
[{"$nulls":15},"年",null,"月から"]
[{"$nulls":4},"死亡の原因"]
[]
[]
["２\n　申請者に\n　関する事\n　項",null,null,null,"所　得　税　の　納　付　状　況",{"$nulls":10},"申請者を扶養する者の状況"]
[]
[{"$nulls":4},"前年の所得について所得税の納付が",{"$nulls":11},"□","申請者を扶養する者がいない"]
[{"$nulls":5},"□","ある",null,null,null,"□","ない"]
[{"$nulls":16},"□","申請者を扶養する者がいるが、その者は前年の"]
[{"$nulls":16},"　所得について所得税を納付していない"]
[{"$nulls":4},"規則16‐0第29条に規定する障害の有無"]
[]
[{"$nulls":4},"障害（障害等級第7級又はそれに相当する程度以上）が",{"$nulls":15},"□","あ　　　る"]
[{"$nulls":20},"□","な　　　い"]
["３　申　請　額",{"$nulls":29},"円"]
[]
["※４",null,"死亡した要介護年金受給権者に係る障害の部位・程度"]
[null,null,"□","神経系統の機能又は精神に著しい障害を残し（有し）、常に介護を要するもの（第１級）"]
[null,null,"□","神経系統の機能又は精神に著しい障害を残し（有し）、随時介護を要するもの（第２級）"]
[null,null,"□","胸腹部臓器の機能に著しい障害を残し（有し）、常に介護を要するもの（第１級）"]
[null,null,"□","胸腹部臓器の機能に著しい障害を残し（有し）、随時介護を要するもの（第２級）"]
[null,null,"傷病等級第１級若しくは第２級又は障害等級第１級若しくは第２級に最初に該当することになった日"]
[{"$nulls":26},"年",null,"月",null,"日"]
["※受理\n　令和　年　月　日",{"$nulls":7},"※決定\n　令和　年　月　日",{"$nulls":7},"※支払\n　令和　年　月　日",{"$nulls":7},"※決定金額\n　　　　　　　　　　　　円"]
[]
["注１　申請者は、※印の欄には記入しないこと。該当する□にレ印を記入すること。\n"]
["　２　この申請書には、人事院規則16‐4（補償及び福祉事業の実施）第24条の2第1項に定めるところによ\n　　"]
[null,"り必要な書類を添付すること。"]