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["別紙第20"]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":5},"遺 族 補 償 年 金 前 払 一 時 金 請 求 書"]
[]
[{"$nulls":15},"請 求 年 月 日",{"$nulls":5},"令和",null,null,null,"年",null,"月",null,"日"]
["（実施機関の長の官職氏名）"]
[{"$nulls":15},"請求者（代表者）の"]
[{"$nulls":15},"住　　　　所"]
[{"$nulls":13},"殿"]
[null,"下記の遺族補償年金前払一時金を請求します。",{"$nulls":13},"氏　　　　名"]
[{"$nulls":15},"死亡職員との続柄"]
[]
["１　請求者（代表者）が選択する遺族補償年金前払\n　　一時金の額",{"$nulls":18},"□","1,000日分",null,null,"（","□","1,080日分）"]
[{"$nulls":19},"□","　800日分"]
[{"$nulls":15},"平均給与額の",null,null,null,"□","　600日分",null,null,"に相当する額"]
[{"$nulls":19},"□","  400日分"]
[{"$nulls":19},"□"," 200日分"]
["２　遺 族 補 償 年 金 前 払 一 時 金 の 請 求 額",{"$nulls":14},"（平均給与額）"]
[{"$nulls":24},1]
[{"$nulls":18},"円","×",null,null,"日分×",{"$nulls":4},"＝",null,null,"円"]
[{"$nulls":24},"（請求者の数）"]
["３　遺族補償年金前払一時金の請求額の合計額"]
[{"$nulls":15},"（２の請求額）",{"$nulls":5},"（請求者の数）"]
[{"$nulls":19},"円×",{"$nulls":5},"＝",{"$nulls":4},"円"]
[]
["４　遺族補償年金前払一時金の申出を行った月まで\n　　の期間に係る遺族補償年金の額の合計額"]
[{"$nulls":18},"年",null,null,"月分から",{"$nulls":4},"年",null,null,"月分まで"]
[{"$nulls":30},"円"]
["５　遺族補償年金の支給決定に関する通知を受けた\n　　年月日"]
[{"$nulls":21},"年",{"$nulls":4},"月",null,null,null,"日"]
[]
[]
[]
["（代表者の氏名）"]
[{"$nulls":7},"を代表者として、遺族補償年金前払一時金の請求及び受領を委任します。"]
[]
["請求者の\n\n同順位者",null,null,"住　　　　　　　　　　　　　　所",{"$nulls":9},"　氏　　　　　　　　　　　　　　名　",{"$nulls":9},"死亡職員との続柄"]
[]
[]
[]
[]
[]
["※受理",{"$nulls":6},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定金額"]
[]
["令和　　年　　月　　日",{"$nulls":6},"令和　　年　　月　　日",{"$nulls":7},"令和　　年　　月　　日",{"$nulls":14},"円"]
[]
["　注１　請求者は、※印の欄には記入しないこと。"]
["　　２　「１　請求者（代表者）が選択する遺族補償年金前払一時金の額」の欄については、請求者（代表者）が\n　　　選択する□にレ印を記入すること。"]
["　　３　「４　遺族補償年金前払一時金の申出を行った月までの期間に係る遺族補償年金の額の合計額」及び\n　　　「５　遺族補償年金の支給決定に関する通知を受けた年月日」の欄には、遺族補償年金の最初の支払に先\n　　　立って申し出る場合は記入しないこと。"]