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["別紙第９"]
[]
[{"$nulls":8},"国家公務員災害補償"]
[{"$nulls":8},"傷病補償年金請求書"]
[{"$nulls":8},"傷病特別給付金支給申請書"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["　 　　　　　　　　　　　　　　　　　　",{"$nulls":13},"※ 年金証書の番号",{"$nulls":4},"第",{"$nulls":4},"号"]
["（実施機関の長の官職氏名）",{"$nulls":12},"請求（申請）年月日",{"$nulls":4},"令和",null,"年",null,"月",null,"日"]
[{"$nulls":13},"請求（申請）者の住所"]
[{"$nulls":12},"殿"]
["下記の",null,"傷病補償年金を請求",{"$nulls":6},"します。"]
[null,null,"傷病特別給付金の支給を申請",{"$nulls":10},"氏名"]
[]
["１（所属部局）",{"$nulls":12},"２（氏名）"]
[{"$nulls":20},"年",null,"月",null,"日生"]
["３（官職）",null,null,"□","常　勤",{"$nulls":8},"４","負傷又は"]
[null,null,null,"□","非常勤",{"$nulls":9},"発病年月日",null,null,null,"令和",null,"年",null,"月",null,"日"]
["５（傷病等級）",{"$nulls":12},"６（傷病等級該当年月日）"]
[{"$nulls":7},"第",null,null,null,"級",{"$nulls":6},"令和",null,"年",null,"月",null,"日"]
["７（傷病の名称、部位及びその状態）"]
["８（既存障害とその程度）"]
["９（日常生活の状態）　　　　　"]
["10　厚生年金保険",{"$nulls":4},"□",null,null,"の被保険者である。",{"$nulls":4},"被保険者証書等の記号番号",{"$nulls":5},"所轄年金事務所等"]
["　　法等の適用",{"$nulls":4},"□","被保険者でない。"]
[11,"通常の場合",{"$nulls":6},"（平均給与額）",{"$nulls":5},"（日数）"]
["傷病補償年金",{"$nulls":11},"円 ×",null,null,null,"＝",null,null,{"$f":"I26*O26","v":0},{"$nulls":4},"円"]
[null,"補償法第14条又は昭和41年"]
[null,"改正法附則第８条の規定"]
[null,"により支給額が制限又は調"]
[null,"整される場合"]
[null,"傷病補償年金請求年額",{"$nulls":22},"円"]
[null,"⑴","（平均給与額）",{"$nulls":5},"（日数）",null,null," （特別給支給率）"]
[12,{"$nulls":5}," 円 ×",null,null,null,"×",{"$nulls":5},"＝",null,null,{"$f":"C33*I33*M33","v":0},{"$nulls":4},"円"]
["傷病特別給付金","⑵","規則16-3第19条の６第１項ただし書による額"]
[{"$nulls":24},"円"]
[null,"⑶","規則16-3第19条の６第２項に該当する場合"]
[null,null,"（平均給与額）",{"$nulls":10},"（年金額）"]
[{"$nulls":6}," 円 ×",null,80,null,"× 365 －",{"$nulls":6},"円 ＝",null,{"$f":"(C38*0.8*365)-N38","v":0},{"$nulls":4},"円"]
[{"$nulls":8},100]
[null," 補償法第14条の規定により\n 支給額が制限される場合"]
[]
[null," 傷病特別給付金支給申請額",{"$nulls":22},"円"]
["13　添付する書類その他の資料名"]
["※受理",{"$nulls":6},"※決定",{"$nulls":6},"※決定\n　年額",null,"傷病補償年金",{"$nulls":7},"円"]
["令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",null,null,"傷病特別給付金",{"$nulls":7},"円"]
["注１　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。"]
["　２ 「７（傷病の名称、部位及びその状態）」の欄の記入事項が添付する診断書の記載事項と同じであるときは、\n　　「診断書のとおり」と記入すること。"]
["　３　この請求（申請）書には、平均給与額算定書、傷病等級の決定に必要な医師の診断書並びに特別給支給率の\n　　算定の基礎を明らかにすることができる書類その他の書類及び資料を添付すること。"]