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["別紙第27"]
[]
["旅 行 費 支 給 申 請 書"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["（実施機関の長の官職氏名）",{"$nulls":13},"申請年月日",{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":13},"殿","（申請者の住所）"]
[]
["　下記の旅行費の支給を受けたいので申請します。",{"$nulls":13},"（氏       名）"]
[]
["１　（所属部局）",{"$nulls":13},"３　（生年月日）"]
[{"$nulls":19},"年",null,null,"月",null,null,"日生"]
["２　（官職）",null,null,"□","常　勤",{"$nulls":9},"４　福祉事業の実施\n　　の承認年月日",{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
[null,null,null,"□","非常勤"]
["５　（旅行の目的）",{"$nulls":5},"□","補装具","（","□","採型",null,"□"," 修理",null,"□","装着",null,"）","□","リハビリテーション"]
["６　（旅行区間）",{"$nulls":4},"　往",{"$nulls":5},"発",{"$nulls":4},"経由",{"$nulls":6},"着"]
[{"$nulls":5},"　復",{"$nulls":5},"発",{"$nulls":4},"経由",{"$nulls":6},"着"]
["７　（旅行期間）",{"$nulls":4},"令和",null,null,"年",null,null,"月",null,null,"日から",null,null,null,"泊",null,null,"日"]
[{"$nulls":5},"令和",null,null,"年",null,null,"月",null,null,"日まで"]
["８　内　訳"]
["月日","出発地",null,"到着地",null,"宿泊地",null,"鉄        道",null,null,"船         舶",null,null,null,"車",null,null,"急  行\n料金等",null,"宿泊数",null,"宿泊料",null,"計"]
[{"$nulls":7},"路程","運賃",null,"路程",null,"運賃",null,"路程","運賃"]
[{"$nulls":7},"キロメートル","円",null,"キロメートル",null,"円",null,"キロメートル","円",null,"円",null,"泊",null,"円",null,"円"]
[]
[]
[]
[]
[]
[]
["合計",{"$nulls":6},{"$f":"SUM(H23:H28)","v":0},{"$f":"SUM(I23:J28)","v":0},null,{"$f":"SUM(K23:L28)","v":0},null,{"$f":"SUM(M23:N28)","v":0},null,{"$f":"SUM(O23:O28)","v":0},{"$f":"SUM(P23:Q28)","v":0},null,{"$f":"SUM(R23:S28)","v":0},null,{"$f":"SUM(T23:U28)","v":0},null,{"$f":"SUM(V23:W28)","v":0},null,{"$f":"SUM(X23:AA28)","v":0}]
["旅行費支給申請額",{"$nulls":20},{"$f":"X29","v":0},{"$nulls":4},"円"]
["※受理　　　　　　　　",{"$nulls":6},"※決定",{"$nulls":6},"※支払",{"$nulls":6},"※決定金額"]
["令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",{"$nulls":5},"円"]
[{"$nulls":21},"添付書類",{"$nulls":4},"枚"]
["　注１　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　「８　内訳」の欄中宿泊料については、その領収書及び明細書を添付すること。"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 　"]