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["別紙第19"]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":8},"障 害 補 償 年 金 前 払 一 時 金 請 求 書"]
[]
[{"$nulls":15},"請 求 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":15},"請求者の住所"]
[{"$nulls":13},"殿"]
[null,"下記の障害補償年金前払一時金を請求します。",{"$nulls":13},"氏　　　　名"]
[]
["１ (障害等級)",{"$nulls":14},"２ (既存障害とその程度)"]
[{"$nulls":6},"第",{"$nulls":6},"級"]
[]
[]
[{"$nulls":15},"□","障害補償年金前払一時金の限度額"]
[]
[{"$nulls":19},"□","1,200日分"]
["３　請求者が選択する障害補償年金前払一時金の額",{"$nulls":18},"□","1,000日分"]
[{"$nulls":15},"平均給与額の",null,null,null,"□","　800日分",null,null,"に相当する額"]
[{"$nulls":19},"□","　600日分"]
[{"$nulls":19},"□"," 400日分"]
[{"$nulls":19},"□"," 200日分"]
[]
[{"$nulls":15},"（１） 限度額を選択した場合"]
[]
[]
[]
["４　障害補償年金前払一時金の請求額",{"$nulls":28},"円"]
[{"$nulls":15},"（２） 限度額以外を選択した場合"]
[{"$nulls":16},"（平均給与額）"]
[]
[]
[{"$nulls":20},"円","×",null,null,"日分＝",{"$nulls":4},"円"]
["５　障害補償年金前払一時金の申出を行った月まで\n　　の期間に係る障害補償年金の額の合計額"]
[{"$nulls":18},"年",null,null,"月分から",{"$nulls":4},"年",null,null,"月分まで"]
[{"$nulls":30},"円"]
[]
["６　障害補償年金の支給決定に関する通知を受けた\n　　年月日"]
[{"$nulls":21},"年",{"$nulls":4},"月",null,null,null,"日"]
[]
[]
[]
["※受理",{"$nulls":6},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定金額"]
[]
["令和　　年　　月　　日",{"$nulls":6},"令和　　年　　月　　日",{"$nulls":7},"令和　　年　　月　　日",{"$nulls":14},"円"]
[]
["　注１　請求者は、※印の欄には記入しないこと。"]
["　　２　「２ (既存障害とその程度)」の欄には、新たに既存の障害を加重した場合に記入するものとし、\n　　　特に既存障害について障害補償を支給された場合は、その該当する障害等級を明記すること。"]
["　　３　「３　請求者が選択する障害補償年金前払一時金の額」の欄については、請求者が選択する□にレ\n　　　印を記入すること。"]
["　　４　「５　障害補償年金前払一時金の申出を行った月までの期間に係る障害補償年金の額の合計額」及\n　　　び「６　障害補償年金の支給決定に関する通知を受けた年月日」の欄には、障害補償年金の最初の支\n　　　払に先立って申し出る場合は記入しないこと。"]