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["別紙第21"]
[]
[{"$nulls":9},"国家公務員災害補償"]
[{"$nulls":9},"未支給の補償請求書"]
[{"$nulls":9},"未支給の福祉事業支給申請書"]
[]
[]
["（実施機関の長の官職氏名）",{"$nulls":15},"請求（申請）年月日",{"$nulls":6},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":16},"請求（申請）者の住所"]
[{"$nulls":14},"殿"]
[]
["下記の",null,"未支給の補償",{"$nulls":11},"を",null,"氏名"]
[null,null,"金銭給付を内容とする未支給の福祉事業の支給"]
["請求",null,"します。",{"$nulls":13},"死亡した",null,null,null,"受給権者",null,null,"との続柄"]
["申請",{"$nulls":19},"職員"]
[]
["　１\n　死 亡 し た\n　受 給 権 者",null,null,null,"氏名"]
[{"$nulls":4},"死亡年月日",{"$nulls":8},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":4},"年金証書の番号",{"$nulls":9},"第",{"$nulls":8},"号"]
["　２\n　未支給の補償",null,null,null,"種　　　　　　　類",{"$nulls":11},"金　　　　　　　額"]
[{"$nulls":30},"円"]
[]
[]
[]
[{"$nulls":4},"（未支給の補償の請求金額）",{"$nulls":25},"円"]
["　３\n　金銭給付を\n　内容とする\n　未支給の\n　福祉事業",null,null,null,"種　　　　　　　類",{"$nulls":11},"金　　　　　　　額"]
[{"$nulls":30},"円"]
[]
[]
[]
[{"$nulls":4},"（未支給の福祉事業の支給申請金額）",{"$nulls":25},"円"]
["  ４ 添付する書類その他の資料名"]
[]
["※受理",{"$nulls":6},"※決定",{"$nulls":6},"※支払",{"$nulls":6},"※決定\n　金額",null," 補償",{"$nulls":6},"円"]
["令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",null,null," 福祉事業",{"$nulls":6},"円"]
["注  １　請求（申請）者は、※印の欄には記入しないこと。"]
["　　２　この請求（申請）書には、死亡した受給権者の死亡を証明する書類その他必要な書類を添付すること。"]