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["別紙第24"]
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["リハビリテ－ション費用支給申請書"]
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["（実施機関の長の官職氏名）　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",{"$nulls":13},"申請年月日",{"$nulls":4},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":14},"（申請者の住所）"]
[{"$nulls":13},"殿"]
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["　　 下記のリハビリテーション費用の支給を受けたい\n　 ので申請します。　　　　　　　　　　　　　　"]
[{"$nulls":14},"（氏　　　名）"]
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["１（所属部局）　　　　　　　　　　　　　　　　",{"$nulls":13},"３（生 年 月 日）"]
[{"$nulls":24},"年",null,null,"月",null,null,"日生"]
["２（官　職）",null,null,"□","常　勤",{"$nulls":9},"４　福祉事業の実施\n　　の承認年月日",{"$nulls":5},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,"□","非常勤"]
["５（傷病名）　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",{"$nulls":13},"６　治 癒 年 月 日",{"$nulls":5},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":14},"７　障　害　等　級",{"$nulls":6},"第",null,null,null,"級","第",null,null,null,"号"]
["８　内　　　容",null,null,null,"期　　　　　　　　　　　間",{"$nulls":8},"金　　　　　　　　　　額（円）"]
[{"$nulls":13},"宿泊料",null,"食事料",null,null,"サービ\nス料",null,null,"訓練指\n導費",null,null,"その他",null,null,"計"]
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[{"$nulls":7},"年",null,"日",null,"日から",{"$nulls":15},{"$f":"N21+P21+S21+V21+Y21","v":0}]
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[{"$nulls":7},"年",null,"月",null,"日まで"]
["リ ハ ビ リ テ ー シ ョ ン 費 用 支 給 申 請 額",{"$nulls":20},{"$f":"AB21+AB23+AB25","v":0},{"$nulls":8},"円"]
["９　利 用 施 設 名 ・ 所 在 地　　　　",{"$nulls":12},"（施設名）"]
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[{"$nulls":13},"（所在地）"]
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["※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":9},"円"]
[{"$nulls":21},"添付書類",{"$nulls":8},"枚"]
["　注１　申請者は、※印の欄には記入しないこと。"]
["　　２　該当する□にレ印を記入すること。"]
["　　３　この申請書には、費用の領収書又はこれに代わる証明書及び明細書を添付すること。"]