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["別紙第５"]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":12},"遺族補償請求書"]
[{"$nulls":12},"遺族特別給付金支給申請書"]
["(年金・一時金)"]
[{"$nulls":24},"※年金証書の番号",{"$nulls":5},"第",{"$nulls":4},"号"]
[null,"（実施機関の長の官職氏名）",{"$nulls":16},"　請求（申請）年月日",{"$nulls":8},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":16},"殿",null,"　請求（申請）者・代表者の住所"]
[null,"下記の",null,null,"遺族補償（年金・一時金）",{"$nulls":11},"を"]
[{"$nulls":4},"遺族特別給付金（年金・一時金）の支給"]
[null,"請　求",null,null,"　します。",{"$nulls":13},"氏名"]
[null,"申　請",{"$nulls":16},"死亡職員との続柄又は関係"]
["１。　\n死亡\n職員\nに関\nする\n事項",null,null,"（所属部局）",{"$nulls":14},"（氏　名）"]
[{"$nulls":30},"年",null,"月",null,"日生"]
[null,null,null,"（官　職）　　　　　　",null,null,"□","常　勤",{"$nulls":10},"（死亡年月日）"]
[{"$nulls":6},"□","非常勤",{"$nulls":19},"令和",null,null,"年",null,"月",null,"日"]
[null,null,null,"厚生年金\n保険法等\nの適用。",null,null,null,"□",{"$nulls":4},"の被保険者であった。",{"$nulls":5},"被保険者証書等の記号番号",{"$nulls":8},"所轄年金事務所等"]
[{"$nulls":7},"□","被保険者でなかった。"]
["２（請求（申請）の事由）",{"$nulls":7},"□","職員の死亡",{"$nulls":7},"□","先順位者の失権"]
[{"$nulls":8},"□","胎児であった子の出生",{"$nulls":7},"□","先順位者の所在不明"]
["３。。。。\n受給権者に\n関する事項",null,null,null,"国民年金\n法の適用",null,null,null,"□","被保険者である。",{"$nulls":5},"被保険者証書等の記号番号",{"$nulls":10},"所轄年金事務所等"]
[{"$nulls":8},"□","被保険者でない。"]
["４。。。。。\n請求(申請)\n者及び遺族\n補償年金を\n受けること\nができる遺族",null,null,null,"氏名",{"$nulls":4},"生年月日",{"$nulls":5},"住所",{"$nulls":10},"死亡職員との続柄又は関係",{"$nulls":6},"備　　考"]
[{"$nulls":15},"　　　　　　　　　　　　"]
[{"$nulls":15},"　　　　　　　　　　　　"]
[{"$nulls":15},"　　　　　　　　　　　　"]
[{"$nulls":15},"　　　　　　　　　　　　"]
[{"$nulls":15},"　　　　　　　　　　　　"]
[{"$nulls":15},"　　　　　　　　　　　　"]
["遺族補償年金",null,"５。\n遺族\n補償\n年金\n請求\n年額\nの\n計算",null,"通常の場合",null,null,null,"（平均給与額）",{"$nulls":8},"（日数）"]
[{"$nulls":15},"円 ×",null,null,null,"×","１",null,null,null,"＝",{"$nulls":10},"円"]
[{"$nulls":20},"（請求者の数）"]
[{"$nulls":4},"昭和41年改正\n法附則第８条\nの規定により\n支給額が調整\nされる場合。"]
[]
[]
[]
[null,null,"６。。。。。\n遺族補償年金\n請求年額",{"$nulls":5},"請求者が１人の場合又は\n代表者を選任しない場合",{"$nulls":26},"円"]
[]
[{"$nulls":8},"代表者を選任した場合",{"$nulls":7},"（５の請求年額）",{"$nulls":5},"（請求者の数）"]
[{"$nulls":21},"円","×",null,null,null,"＝",{"$nulls":8},"円"]
[" 遺族\n 補償\n 一時\n 金。",null,null,"７。。。。。\n遺族補償一時金\n請求額の計算。",{"$nulls":4},"（平均給与額）",{"$nulls":8},"（日数）"]
[{"$nulls":15},"円 ×",null,null,null,"×","１",null,null,null,"＝",{"$nulls":10},"円"]
[{"$nulls":20},"（請求者の数）"]
[null,null,null,"８　遺族補償一時金請求額",{"$nulls":24},{"$f":"AC42","v":0},{"$nulls":6},"円"]
["遺族特別給付金",null,"９。。。\n遺族特別\n給付金支\n給申請額\nの計算。",null,null,"（平均給与額）",{"$nulls":8},"（日数）",null,"  （特別給支給率）"]
[{"$nulls":12},"円 ×",null,null,null,"×",null,null,null,"×","１",null,null,null,"＝",{"$nulls":9},"円"]
[{"$nulls":21},"（申請者の数）"]
[{"$nulls":5},"規則16-3第19条の10第１項ただし書又は第２項ただし書による額"]
[{"$nulls":35},"円"]
[null,null,"10。。。。。。\n遺族特別給付金\n支 給 申 請 額",{"$nulls":5},"申請者が１人の場合又は\n代表者を選任しない場合",{"$nulls":26},"円"]
[]
[{"$nulls":8},"代表者を選任した場合",{"$nulls":7},"（９の申請年額）",{"$nulls":5},"（申請者の数）"]
[{"$nulls":21},"円","×",null,null,null,"＝",{"$nulls":8},"円"]
["11　添付する書類その他の資料名　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定\n　金額",null,"遺族補償",{"$nulls":8},"円"]
["令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日",null,null,"遺族特別給付金",{"$nulls":8},"円"]
["　注１　この請求（申請）書は、補償法第17条の４第１項第２号に該当する場合に支給される遺族補償一時金（失権差額一時金）以外の遺族補償\n　　　一時金の請求及び遺族特別給付金の支給の申請をするときに使用すること。"]
["　　２　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。"]
["　　３　遺族補償年金を受けようとする場合は、「４　請求（申請）者及び遺族補償年金を受けることができる遺族」の欄の備考に、その者が請求者で\n　　　あるときは請、その者が代表者であるときは代、その者が人事院規則16-0（職員の災害補償）第29条に規定する障害の状態にあるときは\n　　　障、また、その者が請求者と生計を同じくしているときは生と明記すること。"]
["　　４　この請求(申請)書には、平均給与額算定書及び特別給支給率の算定の基礎を明らかにすることができる書類その他の必要な書類を添付す\n　　　ること。"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]