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["別紙第35"]
[]
["就 労 保 育 援 護 金 支 給 申 請 書"]
[]
["（実施機関の長の官職氏名）",{"$nulls":29},"令和",null,null,null,"年",null,null,"月",null,null,"日","申請"]
[]
[{"$nulls":14},"殿"]
[]
["　就労保育援護金の支給を受けたいので申請します。"]
[{"$nulls":18},"申請者の住所"]
[]
[{"$nulls":18},"氏名"]
[]
[{"$nulls":18},"被災職員との続柄"]
["１　被災職員に関す\n　　\n　　る事項。。。。",{"$nulls":7},"（所属部局）",{"$nulls":16},"（負傷又は発病年月日）"]
[{"$nulls":36},"年",null,null,"月",null,null,"日",null,"元号はプルダウンから選択してください。"]
[{"$nulls":8},"（氏　名）",{"$nulls":16},"　傷病等級該当、治癒又は"]
[{"$nulls":25},"　死亡の年月日"]
[{"$nulls":8},"（官　職）",{"$nulls":4},"□","常　勤"]
[{"$nulls":13},"□","非常勤",{"$nulls":21},"年",null,null,"月",null,null,"日",null,"元号はプルダウンから選択してください。"]
["２（申請者の受けている補償の種類）　　　　　　　　　　　",{"$nulls":24},"３（年金証書の番号）"]
[null,null,"□","傷病補償年金　　　　　　　　　　　　　　　　　　　　"]
[null,null,"□","障害補償年金",{"$nulls":5},"（障害等級",null,null,null,"第",null,null,"級）",{"$nulls":13},"第",{"$nulls":8},"号"]
[null,null,"□","遺族補償年金　　　　　　　　　　　　　　　　　　　　"]
["４　就労している者に関する事項"]
["就労している者の\n氏名。。。。。。",{"$nulls":22},"生年月日"]
[{"$nulls":36},"年",null,null,"月",null,null,"日生",null,"元号はプルダウンから選択してください。"]
["就労している者の\n住所。。。。。。",{"$nulls":22},"申請者との続柄"]
[]
["就労している会社\n等の名称・所在地"]
[]
["５　保育児に関する事項"]
["氏名"]
["生年月日",{"$nulls":10},"年",null,"月",null,"日生(",null,null,"歳)",{"$nulls":4},"年",null,"月",null,"日生(",null,null,"歳)",{"$nulls":4},"年",null,"月",null,"日生(",null,null,"歳)",null,"元号はプルダウンから選択してください。"]
["住所"]
["申請者との続柄"]
["保育所等の名称"]
["保育所等の所在地"]
["申請月額",{"$nulls":17},"円",{"$nulls":11},"円",{"$nulls":11},"円"]
["※実施機関の承認",{"$nulls":9},"□","承　認",null,null,null,"□","不承認",{"$nulls":5},"□","承　認",null,null,null,"□","不承認",{"$nulls":5},"□","承　認",null,null,null,"□","不承認"]
["※受理",{"$nulls":10},"※決定",{"$nulls":10},"※決定金額",{"$nulls":10},"※通知"]
["令和",null,null,null,"年",null,null,"月",null,null,"日","令和",null,null,null,"年",null,null,"月",null,null,"日",{"$nulls":10},"円","令和",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":33},"添付書類",{"$nulls":9},"枚"]
[]
["　　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。"]