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["別紙第28"]
[]
["ホームヘルプサービス費用支給申請書"]
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["　下記のホームヘルプサービス費用の支給を受けた\nいので申請します。"]
[]
[{"$nulls":15},"氏　　名"]
[]
["（ホームヘルプサービス費用の受領委任）"]
["　この申請書によるホームヘルプサービス費用の受領を",{"$nulls":22},"に委任します。"]
[]
[{"$nulls":14},"氏名"]
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["（委任に基づく支払請求）"]
["　上記委任に基づき、この申請書によるホームヘルプサービス費用の支払を請求します。"]
[{"$nulls":10},"請求者の住所"]
[]
[{"$nulls":10},"氏名"]
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["１（所属部局）",{"$nulls":14},"２（官　職）",null,null,null,"□","常　勤"]
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["４（受けている補償の種類）",{"$nulls":14},"５（年金証書の番号）"]
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[null,null,"□","障害補償年金",null,null,null,"（第",null,null,null,"級）"]
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["７　介護人の賃金等 　",{"$nulls":6},"　内訳は「11介護人の賃金等の証明」欄記載のとおり",{"$nulls":15},{"$f":"'（別紙第２８）２号紙'!Y61","v":0},{"$nulls":4},"円"]
["８　紹介手数料等 　",{"$nulls":6},"　内訳は「12介護人の紹介手数料等の証明｣ 欄記載のとおり",{"$nulls":15},{"$f":"'（別紙第２８）３号紙'!Y51","v":0},{"$nulls":4},"円"]
["９　介護事業者の費用",{"$nulls":6},"　内訳は「13介護事業者の費用の証明｣ 欄記載のとおり",{"$nulls":15},{"$f":"'（別紙第２８）４号紙'!Y63","v":0},{"$nulls":4},"円"]
["10　ホームヘルプサービス費用支給申請額",{"$nulls":22},{"$f":"SUM(X32:AB34)","v":0},{"$nulls":4},"円"]
["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定金額"]
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[]
["　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。　　　　　　　　　"]
["　　　２　「（ホームヘルプサービス費用の受領委任）」の欄には、介護等を行った介護人、介護人の紹介を行った\n　　　　職業紹介所又は介護等の供与を行った介護事業者にホームヘルプサービス費用の受領を委任しようとする場\n　　　　合にのみ記載し、その他の場合には記入しないこと。"]
["　　　３　２号紙、３号紙又は４号紙の記入に代えて同様事項を記載した介護人、職業紹介所又は介護事業者の証明\n　　　　書を添付してもよい。"]

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["※11　介護人の賃金等の証明　　　　　　　　　　",{"$nulls":16},"（介護等を受けた者の氏名）　　　　　　　　　　　"]
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["賃金請求額の合計（Ｃ）",{"$nulls":26},{"$f":"SUM(AB5:AE49)","v":0},null,null,null,"円"]
["交　　通　　費　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["年月日",{"$nulls":4},"経　　路（交通機関）",{"$nulls":6},"金　　額",null,null,null,"年月日",{"$nulls":4},"経　　路（交通機関）",{"$nulls":6},"金　　額"]
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["　上記の事項は事実と相違ないことを証明します。　　　　　　　　　　　　　　　　　　　　　　　　　"]
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[{"$nulls":12},"氏名"]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]

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[{"$nulls":31},"３号紙"]
["※12　介護人の紹介手数料等の証明　　　　　　　　　　",{"$nulls":16},"（介護等を受けた者の氏名）　　　　　　　　　　　"]
["実施年月日",{"$nulls":8},"時間帯",null,null,null,"介護等の種類",null,null,null,"紹　介\n手数料",null,null,"受　付\n手数料",null,null,"労災保険特\n別加入保険\n料に充てる\nべき手数料",null,null,"合　計",null,null,"紹　介\n介護人\n氏　名"]
[]
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["13","令和",null,null,"年",null,"月",null,"日",null,"時",null,"分","□","介護",{"$nulls":4},"円",null,null,"円",null,null,"円",{"$f":"R42+U42+X42","v":0},null,"円"]
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["14","令和",null,null,"年",null,"月",null,"日",null,"時",null,"分","□","介護",{"$nulls":4},"円",null,null,"円",null,null,"円",{"$f":"R45+U45+X45","v":0},null,"円"]
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["15","令和",null,null,"年",null,"月",null,"日",null,"時",null,"分","□","介護",{"$nulls":4},"円",null,null,"円",null,null,"円",{"$f":"R48+U48+X48","v":0},null,"円"]
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["介護人の紹介手数料等の合計",{"$nulls":23},{"$f":"SUM(AA6:AB50)","v":0},{"$nulls":6},"円"]
["　上記の事項は事実と相違ないことを証明します。　　　　　　　　　　　　　　　　　　　　　　　　　"]
[null,"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":11},"所在地"]
[{"$nulls":6},"職業紹介所の",{"$nulls":4},"名称"]
[{"$nulls":11},"代表者氏名"]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]

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[{"$nulls":31},"４号紙"]
["※13　介護事業者の費用の証明　　　　　　　　　　",{"$nulls":16},"（介護等を受けた者の氏名）　　　　　　　　　　　"]
["実施年月日",{"$nulls":8},"時間帯",null,null,null,"介護等\nの種類",null,null,null,"賃金相当額\n（Ａ）",null,null," 介護等の供与を受けるのに\n 必要な費用のうち賃金相当\n 額以外の費用の内訳\n　　　　  （Ｂ）",{"$nulls":5},"申請者\n負担額\n（Ｃ）",null,null,"請求額\n(Ａ)+(Ｂ)\n－(Ｃ)"]
[]
[]
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