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["別紙第17"]
["国 家 公 務 員 災 害 補 償"]
["行　方　不　明　補　償　請　求　書"]
[]
[{"$nulls":26},"請求回数",null,null,null,"第",null,null,"回"]
["(実施機関の長の官職氏名)",{"$nulls":15},"請求年月日",{"$nulls":8},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":16},"請求者の住所"]
[]
[{"$nulls":14},"殿",null,"　　　　　　　　　　　　　　　　　　　　　　　　"]
[null,"下記の行方不明補償を請求します。"]
[{"$nulls":16},"氏　名"]
[]
[{"$nulls":16},"行方不明職員との続柄又は関係"]
[]
["１\n行方不明職\n員に関する\n事項",null,null,"（所属部局）",{"$nulls":12},"（氏名）"]
[]
[null,null,null,"（官職）",null,null,"□","常　勤"]
[{"$nulls":6},"□","非常勤",{"$nulls":18},"年",null,null,"月",null,null,"日","生"]
["２　行方不明補償請求期間"]
[null,"令和",{"$nulls":6},"年",{"$nulls":5},"月",{"$nulls":5},"日から",{"$nulls":7},"日間"]
[null,"令和",{"$nulls":6},"年",{"$nulls":5},"月",{"$nulls":5},"日まで"]
["３\n行方不明\n補償を受\nけること\nができる\n被扶養者",null,null,"氏　　　　　名",{"$nulls":6},"生　年　月　日",{"$nulls":6},"住　　　　　　所",{"$nulls":11},"行方不明職員と\nの続柄又は関係"]
{"$rows_empty":7}
["４　行方不明補償\n　請求金額の計算",{"$nulls":4},"（平均給与額）",{"$nulls":19},"（請求日数）"]
[{"$nulls":9},"円","×","１",null,null,null,"＝",null,null,null,"円",null,null,null,"円",null,"✕",null,null,null,"＝",null,null,null,"円"]
[{"$nulls":11},"（請求者の数）"]
["５　行方不明補償請求金額"]
[{"$nulls":33},"円"]
["※\n６\n所属\n官署\n等の\n長の\n証明",null,"行方不明の期間",{"$nulls":11},"行方不明となった原因",{"$nulls":12},"死亡の確認"]
[null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日から",{"$nulls":16},"□","確　認"]
[null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日まで",{"$nulls":16},"□","未確認"]
[null,null,"上記のとおりであると認めます。"]
[]
[{"$nulls":4},"令和",null,null,"年",null,"月",null,"日",{"$nulls":5},"所在地"]
[{"$nulls":9},"所属官署又は所属事務所の",{"$nulls":7},"名称"]
[{"$nulls":17},"長の官職氏名"]
[null,"添付書類",{"$nulls":17},"枚"]
["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定金額"]
["令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日",{"$nulls":9},"円"]
[]
["　注１　請求者は、※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　この請求書には、平均給与額算定書を添付すること。ただし、第２回目以後の請求において"]
["　　　平均給与額に変更がない場合は、平均給与額算定書を添付しなくてよい。"]
["　　３　この請求書には、請求者が人事院規則１６―２（在外公館に勤務する職員、船員である職員等"]
["　　　に係る災害補償の特例）第８条第３項に該当する者であることを証明する書類を添付すること。"]
["　　　ただし、第２回目以後の請求において行方不明補償を受けようとする者に変更がない場合は、"]
["　　　当該書類を添付しなくてよい。"]