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["別紙第56"]
[]
["国 家 公 務 員 災 害 補 償"]
["遺  族  の　現　状　報　告　書"]
[]
[]
["(実施機関の長の官職氏名)",{"$nulls":19},"令和",null,null,null,"年",null,"月",null,"日"]
[]
[{"$nulls":11},"殿"]
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["　下記のとおり遺族の現状を報告します。"]
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[{"$nulls":6},"報告者の年金証書の番号　　",{"$nulls":9},"第",{"$nulls":4},"号"]
[]
[{"$nulls":8},"住        所"]
[]
[{"$nulls":8},"氏　　　　名"]
[]
[]
[]
[]
["１　死亡職員の氏名"]
[{"$nulls":20},"（死亡年月日",null,null,"年",null,"月",null,"日）"]
[" ２\n 遺族補\n 償年金\n を受け\n ること\n ができ\n る遺族",null,"氏　　　名",{"$nulls":4},"生　年　月　日",null,null,null,"住　　　　　　所",{"$nulls":7},"死亡職員\nとの続柄",null,null,"障害の\n有　無",null,"報告者と生計を同\nじくしているか"]
[]
[{"$nulls":22},"有・無"]
[]
[{"$nulls":22},"有・無"]
[]
[{"$nulls":22},"有・無"]
[]
[{"$nulls":22},"有・無"]
[]
[{"$nulls":22},"有・無"]
[]
[{"$nulls":22},"有・無"]
[]
[{"$nulls":22},"有・無"]
[]
[" ３\n 公的年\n 金の受\n 給関係",null,"年　　金　　の　　種　　類",{"$nulls":7},"年 金 の 年 額",{"$nulls":6},"年金証書の\n記号番号",null,null,null,"支給開始年月",null,null,null,"所 轄 年 金\n事 務 所 等"]
[]
[]
[]
[]
[]
["４　添付する書類\n    その他の資料名"]
[]
[]
[]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]