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["別紙第４"]
[]
["国 家 公 務 員 災 害 補 償"]
["介　護　補　償　請　求　書"]
[]
[{"$nulls":23},"請求",null,"第",null,null,"回"]
[]
[{"$nulls":23},"回数"]
["(実施機関の長の官職氏名)",{"$nulls":15},"請求年月日",{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":16},"請求者の住所"]
[{"$nulls":15},"殿"]
["下記の介護補償を請求します。",{"$nulls":15},"氏名"]
[]
["１（所属部局）",{"$nulls":15},"２（氏　名）"]
[{"$nulls":24},"年",null,"月",null,"日生"]
["３（官　職）",null,null,"□","常　勤",{"$nulls":11},"４　負 傷 又 は"]
[null,null,null,"□","非常勤",{"$nulls":11},"　　発病年月日",{"$nulls":4},"令和",null,null,"年",null,"月",null,"日"]
["５（受けている年金の種類）",{"$nulls":15},"６（年金証書の番号）"]
["□","傷病補償年金(傷病等級第",{"$nulls":7},"級 第",null,null,null,"号）"]
["□","障害補償年金(障害等級第",{"$nulls":7},"級 第",null,null,null,"号）",{"$nulls":7},"第",{"$nulls":5},"号"]
["７（障害の部位及びその程度並びに当該障害に伴う日常生活の状態）",{"$nulls":15},"８（介護を要する状態の区分）"]
[{"$nulls":17},"□","常時介護を要する状態"]
[{"$nulls":17},"□","随時介護を要する状態"]
["９　請求内容","請　求　対　象　年　月",{"$nulls":7},"介護に要する費用\nとして支出した額",{"$nulls":6},"親族等から介護を\n受けた日の有無",{"$nulls":4},"請　求　月　額"]
[]
[null,"令和",null,null,"年",null,"月",{"$nulls":8},"円","□","有",null,"□","無",{"$nulls":7},"円"]
[null,"令和",null,null,"年",null,"月",{"$nulls":8},"円","□","有",null,"□","無",{"$nulls":7},"円"]
["10（介護を受けた場所）"]
["□","自宅"]
["□","病院・施設等（名称：",{"$nulls":19},"）"]
[null,"入院（入所）期間",{"$nulls":6},"令和",null,null,"年",null,null,"月",null,"日 ～ 令和",{"$nulls":4},"年",null,null,"月",null,null,"日"]
["11。。　　\n親族等\nで介護\nに従事\nした者",null,"氏名",null,null,null,"請求者との続柄又は関係",{"$nulls":5},"請求者が介護を受けた期間"]
[{"$nulls":12},"令和",null,null,"年",null,"月",null,"日","～","令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":12},"令和",null,null,"年",null,"月",null,"日","～","令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":12},"令和",null,null,"年",null,"月",null,"日","～","令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":12},"令和",null,null,"年",null,"月",null,"日","～","令和",null,null,"年",null,"月",null,"日"]
["12　介護補償請求金額",{"$nulls":27},"円"]
["13　添付する書類その他の資料名"]
["※受理",{"$nulls":6},"※決定",{"$nulls":7},"※支払",{"$nulls":6},"※決定金額"]
["令和",null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日","令和",null,"年",null,"月",null,"日",{"$nulls":6},"円"]
["注１　請求者は、※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。"]
["　２　「７　（障害の部位及びその程度並びに当該障害に伴う日常生活の状態）」の欄については、第１回目の請求を行\n　　う場合及び第２回目以降の請求において介護を要する状態に変更があった場合にのみ記入することとし、記入事項が\n　　添付する医師等の証明書又はその写しの記載事項と同じであるときは「証明書のとおり」と記入すること。"]
["　３　この請求書には、常時又は随時介護を要する状態にあることの決定に必要な医師等の証明書又はその写しその\n　　他必要な書類を添付すること。ただし、第２回目以降の請求において介護を要する状態に変更がない場合は、医\n　　師等の証明書又はその写しを添付しなくてもよい。"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]