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["別紙第32"]
[]
[{"$nulls":9},"遺族特別支給金",{"$nulls":8},"支給申請書"]
[{"$nulls":9},"遺族特別援護金"]
[]
["（実施機関の長の官職氏名）",{"$nulls":15},"申請年月日",{"$nulls":8},"令和",null,null,"年",null,"月",null,"日"]
[]
["　　　　　　　　　　　　　　　　",{"$nulls":14},"殿","申請（代表）者の住所"]
[]
[null,"下記の",null,null,"遺族特別支給金",{"$nulls":4},"の支給を申請します。"]
[{"$nulls":4},"遺族特別援護金",{"$nulls":11},"氏名"]
[]
["　１　死亡職員に関する事項"]
["（所属部局）　　　　　　　　　　　　　　　　",{"$nulls":15},"（氏　名）"]
["　　　　　　　　　　　　　　　　　　　　　　"]
["（官　職）",{"$nulls":11},"（死亡年月日）",{"$nulls":8},"（災害の種類）"]
[null,"□","常　勤",{"$nulls":21},"□","公務上の災害"]
[null,"□","非常勤",{"$nulls":10},"令和",null,null,"年",null,"月",null,"日",null,null,null,"□","通勤による災害"]
[]
["２　特別支給金及び特別援護金の支給を受けることができる遺族に関する事項"]
["氏名",{"$nulls":11},"生年月日",{"$nulls":8},"死亡職員との続柄又は関係"]
[]
[]
[]
[]
["３　遺族特別支給金支給申請額"]
[{"$nulls":32},"円"]
["４　遺族特別援護金支給申請額"]
[{"$nulls":32},"円"]
["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定",null,"特別支給金",{"$nulls":5},"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","　金額",null,"特別援護金",{"$nulls":5},"円"]
["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。"]