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["別紙第11"]
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["国 家 公 務 員 災 害 補 償"]
["傷 病 補 償 年 金 変 更 請 求 書"]
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["(実施機関の長の官職氏名)",{"$nulls":15},"請求年月日",{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
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[{"$nulls":16},"年金証書の番号",{"$nulls":4},"　第",{"$nulls":6},"号"]
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[{"$nulls":11},"殿",{"$nulls":4},"請求者の住所"]
[{"$nulls":14},"殿"]
["　下記のとおり、傷病等級に変更があっ"]
["たので、傷病補償年金の支給の決定を請"]
["求します。",{"$nulls":15},"氏　　　名"]
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[]
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["１　現在受けている傷病補償年金\n　　の傷病等級",{"$nulls":11},"第",{"$nulls":14},"級"]
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["２　現在受けている傷病補償年金\n　　の支給が開始された年月",{"$nulls":20},"年",{"$nulls":5},"月"]
[]
["３　障害の程度に変更があった年\n　　月日",{"$nulls":11},"令和",{"$nulls":6},"年",null,null,null,"月",null,null,null,"日"]
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["４　傷病の名称、部位及びその\n　　状態"]
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["５　変更後の傷病等級",{"$nulls":11},"第",{"$nulls":14},"級"]
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["６　傷病補\n　　償年金\n　　の請求\n　　年額の\n　　計算",null,null,"通　常　の　場　合",{"$nulls":4},"（平均給与額）",{"$nulls":6},"（日数）","（日数）"]
[{"$nulls":12},"円×",{"$nulls":5},"＝",{"$nulls":9},"円"]
[null,null,null,"補償法第14条又は昭和41年改正法附則第８条の規定により支給額が制限され又は調整される場合"]
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["７　傷病補償年金請求年額",{"$nulls":27},"円"]
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["８　添付する書類その他の資料名"]
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["※受理　令和　年　　月　　日",{"$nulls":7},"※決定　令和　年　　月　　日",{"$nulls":9},"※決定年額",{"$nulls":9},"円"]
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["注１　請求者は、※印の欄には記入しないこと。"]
["　２　「４　傷病の名称、部位及びその状態」の欄の記入事項が添付する診断書の記載事項と同じであ"]
["　　るときは「診断書のとおり」と記入すること。"]
["　３　この請求書には、障害の程度に変更があった時期の決定及び変更後の傷病等級の決定に必要な医"]
["　　師の診断書その他の書類及び資料を添付すること。"]
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["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]