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["別紙第13"]
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["国 家 公 務 員 災 害 補 償"]
["障 害 補 償 変 更 請 求 書"]
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["(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"]
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[{"$nulls":16},"年金証書の番号",{"$nulls":4},"　第",{"$nulls":6},"号"]
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[{"$nulls":16},"請求者の住所"]
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[{"$nulls":11},"殿",null,null,"殿"]
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["　下記のとおり、障害等級に変更があったの",{"$nulls":15},"氏　　　名"]
["で、障害補償年金の支給の決定又は障害補償"]
["一時金の支給を請求します。"]
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["１　現在受けている障害補償年金\n　　の障害等級",{"$nulls":11},"第",{"$nulls":14},"級"]
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["２　現在受けている障害補償年金\n　　の支給が開始された年月",{"$nulls":20},"年",{"$nulls":5},"月"]
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["３　障害の程度に変更があった年\n　　月日",{"$nulls":11},"令和",{"$nulls":6},"年",null,null,null,"月",null,null,null,"日"]
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["４　障害の部位及びその程度"]
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["５　変更後の障害等級",{"$nulls":11},"第",{"$nulls":14},"級"]
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[" ６\n 障害補償年\n 金の請求年\n 額又は障害\n 補償一時金\n の請求金額\n の計算",null,null,"通　常　の　場　合",{"$nulls":4},"（平均給与額）",{"$nulls":6},"（日数）","（日数）"]
[{"$nulls":12},"円×",{"$nulls":5},"＝",{"$nulls":9},"円"]
[null,null,null,"補償法第14条又は昭和41年改正法附則第８条の規定により支給額が制限され又は調整される場合"]
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["７　障害補償",null,null,"年金請求年額",{"$nulls":24},"円"]
[null,null,null,"一時金請求年額"]
["８　添付する書類その他の資料名"]
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["※受理　令和　年　月　日",{"$nulls":7},"※決定　令和　年　月　日",{"$nulls":9},"※決定",null,"年額",{"$nulls":7},"円"]
[{"$nulls":20},"金額"]
["注１　請求者は、※印の欄には記入しないこと。"]
["　２　「４　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」と記入すること。"]
["　３　この請求書には、障害の程度に変更があった時期の決定及び変更後の障害等級の決定に必要な医"]
["　　師の診断書その他の書類及び資料を添付すること。"]
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["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]