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["別紙第６"]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":7},"遺族補償一時金（失権差額一時金）請求書"]
[{"$nulls":7},"遺族特別給付金支給申請書"]
[]
[{"$nulls":29},"１号紙"]
["（実施機関の長の官職氏名）",{"$nulls":16},"請求（申請）年月日",{"$nulls":5},"令和",null,"年",null,"月",null,"日"]
[{"$nulls":15},"殿",null,"請求（申請）者の住所"]
[]
["下記の",null,"遺族補償一時金を請求",{"$nulls":8},"します。"]
[null,null,"遺族特別給付金の支給を申請",{"$nulls":14},"氏名"]
[{"$nulls":17},"死亡職員との続柄又は関係"]
["１\n死亡職員\nに関する\n事項",null,null,"（所属部局）",{"$nulls":13},"（氏　名）"]
[{"$nulls":25},"年",null,"月",null,"日生"]
[null,null,null,"（官　職）",{"$nulls":13},"（死亡年月日）",{"$nulls":5},"令和",null,"年",null,"月",null,"日"]
[null,null,null,"□","常　勤"]
[null,null,null,"□","非常勤",{"$nulls":12},"（年金証書の番号）",{"$nulls":5},"第",{"$nulls":5},"号"]
["２\n一時金の\n受給権者　に関する\n事項",null,null,"氏名",{"$nulls":7},"生年月日",{"$nulls":8},"死亡職員との続柄又は関係"]
[]
[]
[]
[]
[]
["３　遺族補償一時金"]
[null,"（平均給与額）",{"$nulls":9},"（Ｄ）"]
["（",{"$nulls":4},"円 ×",null,null,null,"日分 －",{"$nulls":5},"円）×",null,"１",{"$nulls":4},"＝",{"$nulls":6},"円"]
[{"$nulls":17},"（受給権者の数）"]
["（遺族補償一時金請求額）"]
[{"$nulls":29},"円"]
["４　遺族特別給付金"]
[null,"（平均給与額）",{"$nulls":7},"（特別給支給率）",{"$nulls":4},"（Ｇ）"]
["⑴（",{"$nulls":4},"円 ×",null,null,null,"日分 ×",null,null,null,"－",{"$nulls":4},"円）×",null,"１",null,null,null,"＝",{"$nulls":4},"円"]
[{"$nulls":20},"（申請者の数）"]
["⑵ 規則16-3第19条の10第３項の規定に基づき150万円を基礎として算定した額"]
[{"$nulls":29},"円"]
["（遺族特別給付金支給申請額）"]
[{"$nulls":29},"円"]
["５　添付する書類その他の資料名"]
["※受理",{"$nulls":6},"※決定",{"$nulls":6},"※支払",{"$nulls":6},"※決定\n　金額",null,"遺族補償一時金",{"$nulls":5},"円"]
["令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",null,null,"遺族特別給付金",{"$nulls":5},"円"]
["　注１　この請求（申請）書は、補償法第17条の４第１項第２号に該当する場合に支給される遺族補償一時金（失権差額一時\n　　　金）の請求及び遺族特別給付金の支給の申請をするときに使用すること。"]
["　　２　請求（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。"]
["　　３　この請求（申請）書には、平均給与額算定書及び特別給支給率の算定の基礎を明らかにすることができる書類"]
["　　　その他の必要な書類を添付すること。"]

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[{"$nulls":23},"２号紙"]
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["６　既に支給された遺族補償年金又は遺族補償年金前払一時金の計算"]
["遺族補償年金が支給されていた場合"]
["受給権者であった者の氏名",{"$nulls":5},"年金証書の番号",{"$nulls":5},"支給された年金額の合計",{"$nulls":5},"支給された特別給付金額の合計"]
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["遺族補償年金前払一時金が支給されていた場合"]
["支給年月日",{"$nulls":6},"支給された前払一時金の額(Ａ´)",{"$nulls":5},"人事院が定める率(Ｂ´)",{"$nulls":4},"(Ａ´)×(Ｂ´)"]
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[{"$nulls":5},"総　　　　計(Ｃ)＋(Ｃ´) ",{"$nulls":16},"円（Ｄ）"]
["７　既に支給された遺族特別給付金の計算"]
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[{"$nulls":4},"(平均給与額)×(日数)×(特別給支給率)"]
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