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["別紙第30"]
[]
["傷 病 特 別 支 給 金 支 給 申 請 書"]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["（実施機関の長の官職氏名）　　　　　　　　",{"$nulls":14},"申請年月日",{"$nulls":6},"令和",null,null,"年",null,"月",null,"日"]
["　　　　　　　　　　　　　　　　　　　　　",{"$nulls":14},"申請者の住所"]
[{"$nulls":14},"殿"]
[]
["　下記の傷病特別支給金の支給を申請します。　",{"$nulls":14},"氏名"]
[]
["１（所属部局）　　　　　　　　　　　　　　",{"$nulls":14},"２（官　職）",null,null,null,"□","常　勤"]
["　　　　　　　　　　　　　　　　　　　　　",{"$nulls":18},"□","非常勤"]
["３（負傷又は発病年月日）　　　　　　　　　",{"$nulls":14},"４（傷病等級該当年月日）"]
[]
[null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日",{"$nulls":4},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["５（傷病等級）"]
[]
[null,null,null,"第",{"$nulls":9},"級"]
["６　傷病特別支給金支給申請額の計算"]
["通常の場合",{"$nulls":14},"支給額が制限される場合"]
["　　　　　　　　　　　　　　　　　　　　　"]
[]
[]
[]
[]
["（傷病特別支給金支給申請額）"]
[]
[{"$nulls":29},"円"]
["※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":5},"円"]
[]
["　 注　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。"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]