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[null,"別紙第３"]
[null,"国 家 公 務 員 災 害 補 償"]
[{"$nulls":10},"障害補償請求書"]
[{"$nulls":10},"障害特別給付金支給申請書"]
[null,"(年金・一時金)"]
[{"$nulls":18},"※年金証書の番号",{"$nulls":5},"第",{"$nulls":6},"号"]
[null,"(実施機関の長の官職氏名)",{"$nulls":15},"請求（申請）年月日",{"$nulls":6},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":14},"殿",null,null,"請求（申請）者の住所"]
[null,"下記の",null,null,"障害補償（年金・一時金）",{"$nulls":10},"を"]
[{"$nulls":4},"障害特別給付金（年金・一時金）の支給"]
[null,"　請　求",null,null,"します。",{"$nulls":12},"氏　　名"]
[null,"　申　請"]
[null,"１（所属部局）",{"$nulls":15},"２（氏　名）"]
[{"$nulls":27},"年",null,"月",null,"日生"]
[null,"３（官　職）",null,null,null,"□","常　勤",{"$nulls":10},"４　負 傷 又 は"]
[{"$nulls":5},"□","非常勤",{"$nulls":10},"　　発病年月日",{"$nulls":6},"令和",null,null,"年",null,"月",null,"日"]
[null,"５（障害等級）",{"$nulls":15},"６（治癒年月日）"]
[{"$nulls":10},"第",null,null,null,"　級",{"$nulls":9},"令和",null,null,"年",null,"月",null,"日"]
[null,"７（障害の部位及びその程度）"]
[null,"８（既存障害とその程度）"]
[null,"９ 　厚生年金保険",{"$nulls":4},"□",{"$nulls":4},"の被保険者である。",{"$nulls":5},"被保険者証書等の記号番号",{"$nulls":7},"所轄年金事務所等"]
[null,"　 　法等の適用",{"$nulls":4},"□","被保険者でない。"]
[null,"　　障害補償（年金・一時金）",null,"通常\nの\n場合",null,"（平均給与額）",{"$nulls":6},"（日数）"]
[{"$nulls":10},"円 ×",null,null,null,"＝",{"$nulls":10},{"$f":"F24*N24","v":0},{"$nulls":5},"円"]
[null,null,null,"障害\n加重\nの\n場合",null,"第７級\n以　上",null,null,"加重前の障害の程度が第７級以上の障害等級に該当する場合",{"$nulls":22},"円"]
[{"$nulls":8},"加重前の障害の程度が第８級以下の障害等級に該当する場合",{"$nulls":22},"円"]
[{"$nulls":5},"第８級\n以　下"]
[{"$nulls":31},"円"]
[null,null,null,"補償法第14条又は昭和41年\n改正法附則第８条の規定\nにより支給額が制限又は調\n整される場合。。。。。。"]
[]
[]
[]
[null,null,null,"障害補償請求金額",{"$nulls":7},"(年金)",{"$nulls":9},"(一時金)"]
[{"$nulls":20},"円",{"$nulls":10},"円"]
[null,"障害特別給付金",null,"通常\nの\n場合",null,"（平均給与額）",{"$nulls":6},"（日数）",null,null,"（特別給支給率）"]
[{"$nulls":10},"円 ×",null,null,null,"×",{"$nulls":5},"＝",{"$nulls":4},{"$f":"F36*M36*P36","v":0},{"$nulls":5},"円"]
[{"$nulls":5},"規則16-3第19条の7第1項ただし書又は同条第2項ただし書による額"]
[{"$nulls":31},"円"]
[null,null,null,"障害\n加重\nの\n場合",null,"第７級\n以　上",null,null,"加重前の障害の程度が第７級以上の障害等級に該当する場合",{"$nulls":22},"円"]
[{"$nulls":8},"加重前の障害の程度が第８級以下の障害等級に該当する場合",{"$nulls":22},"円"]
[{"$nulls":5},"第８級\n以　下"]
[{"$nulls":31},"円"]
[null,null,null,"補償法第14条の規定により\n支給額が制限される場合。"]
[]
[null,null,null,"障害特別給付金支給申請額",{"$nulls":7},"(年金)",{"$nulls":9},"(一時金)"]
[{"$nulls":20},"円",{"$nulls":10},"円"]
[null,"12　添付する書類その他の資料名"]
[null,"※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":5},"※決定\n　金額",null,"障害補償",{"$nulls":5},"円"]
[null,"令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日","　令和　年　月　日",{"$nulls":7},"障害特別給付金",{"$nulls":5},"円"]
[null,"　注１　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。"]
[null,"　　２　「７　(障害の部位及びその程度)」の欄の記入事項が添付する診断書の記載事項と同じであるときは、「診断書のとおり」\n　　　と記入すること。"]
[null,"　　３　「８　(既存障害とその程度)」の欄には、新たに既存の障害の程度を加重した場合に記入するものとし、既存障害について\n　　　障害補償を支給された場合は、その該当する障害等級を明記すること。"]
[null,"　　４　この請求(申請)書には、平均給与額算定書、治癒の時期の決定及び障害等級の決定に必要な医師の診断書並びに特別給支\n　　　給率の算定の基礎を明らかにすることのできる書類その他の書類及び資料を添付すること。"]