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["別紙第31"]
[]
[{"$nulls":9},"障害特別支給金",{"$nulls":8},"支給申請書"]
[{"$nulls":9},"障害特別援護金"]
[]
["（実施機関の長の官職氏名）",{"$nulls":15},"申請年月日",{"$nulls":8},"令和",null,null,"年",null,"月",null,"日"]
[]
["　　　　　　　　　　　　　　　　",{"$nulls":14},"殿","申請者の住所"]
[]
[null,"下記の",null,null,"障害特別支給金",{"$nulls":4},"の支給を申請します。"]
[{"$nulls":4},"障害特別援護金",{"$nulls":11},"氏名"]
[]
["１（所属部局）　　　　　　　　　　　　　　　　",{"$nulls":15},"２（官　職）"]
["　　　　　　　　　　　　　　　　　　　　　　　",{"$nulls":19},"□","常　勤"]
[{"$nulls":20},"□","非常勤"]
["３（負傷又は発病年月日）　　　　　　　　　　　",{"$nulls":15},"４（治癒年月日）"]
[]
[{"$nulls":4},"令和",null,null,null,"年",null,null,"月",null,null,"日",{"$nulls":5},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["５（災害の種類）",{"$nulls":15},"６（障害等級）"]
[{"$nulls":5},"□","公務上の災害"]
[{"$nulls":5},"□","通勤による災害",{"$nulls":13},"第",{"$nulls":5},"級"]
[]
["７\n\n\n特　別\n\n\n支給金\n",null,null,"通常の場合",{"$nulls":8},"加重障害の場合",{"$nulls":7},"　　　傷病特別支給金\n　　　を受けた場合",{"$nulls":6},"　　 支給額が制限\n　　 される場合"]
[]
[]
[]
[]
[null,null,null,"（障害特別支給金支給申請額）"]
[]
[{"$nulls":32},"円"]
["８\n\n\n特　別\n\n\n援護金",null,null,"通常の場合",{"$nulls":12},"加重障害の場合"]
[]
[]
[]
[]
[null,null,null,"（障害特別援護金支給申請額）"]
[{"$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。"]