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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○で囲む部分"]
[null,null,"(様式第7号)"]
[null,null,null,null,null,"南信地域町村交通災害共済見舞金請求書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　この様式にパソコンで直接入力する場合は、図形の部分（○で囲む部分）が変更できませんので、手で書き込んでください。"]
[null,"※　二重線枠内の留意事項を必ずご確認のうえ、漏れのないようにご記入ください。"]
[null,null,"住所"]
[null,null,"世帯主氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連  絡  先\n電話番号",null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,"）"]
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[null,null,"共済加入者\n（死傷者）氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,"生年月日",null,null,null,null,null,"T",null,"S",null,null,null,null,"年",null,null,null,null,"月",null,null,null,"日"]
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[]
[null,null,"共済加入者が\n未成年者の場合",null,null,null,null,"親権者\n氏　  名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続 柄",null,null,null,null,"加入者（死傷者）の"]
[]
[null,null,"事故発生日時",null,null,null,null,"令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"午",null,null,null,null,null,null,null,null,"時",null,null,null,null,"分頃"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同意・請求者氏名欄"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　この様式にパソコンで直接入力する場合は、フリガナが自動で出力しますので、苗字と名前の間を1字空け、読み仮名どおりに漢字で入力してください。\n　フリガナを修正したときは、保存をしないか、別の名前で保存してください。"]
[null,null,"見舞金請求区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※　留意事項\n　シャチハタ等インクを使ったスタンプ印での請求は、無効となりますのでご注意ください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"フリガナ",null,null,null,{"$f":"ASC(PHONETIC(AC23))","v":""}]
[null,null,"照会に対する同意\n及び見舞金請求\n（必ずご確認ください。）",null,null,null,null,"　私は、本共済見舞金の認定に関して、必要な事項を直接組合から関係機関等へ照会することに同意し、共済見舞金を請求しますので、下記口座に振り込んでください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同　意\n請求者\n氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"㊞"]
[]
[null,null,"共済見舞金\n振込口座"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"口座番号"]
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[null,null,"請求者と異なる\n口座名義の場合",null,null,null,null,"フリガナ",null,{"$f":"ASC(PHONETIC(J32))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続 柄",null,null,null,null,"加入者（死傷者）の"]
[null,null,null,null,null,null,null,"氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同意・請求者と同じです。"]
[null,null,"添付書類",null,null,null,null,"交通事故\n証　明　書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"救急車出動証明又は入手不能理由書",null,null,null,null,null,null,null,null,null,null,"町村長の\n事故証明"]
[]
[]
[]
[null,null,null,null,null,null,null,"医  師  の\n診  断  書",null,null,null,null,null,null,null,null,null,"診断書の\n領  収  書",null,null,null,null,null,null,null,null,null,"その他"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　役場の担当の方が記入又は入力してください。"]
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[null,null,"　上記のとおり共済見舞金の請求があったので、進達します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(COUNTA(H9)=1,IF(AW44=0,0,\"ERROR 次の処理をしてください\"),\"\")","v":""},null,null,{"$f":"IF(K40=0,1,IF(Q40=0,2,IF(U40=0,3,IF(AI40=0,4,0))))","v":1}]
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[null,null,null,null,"令和",null,null,"年",null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(COUNTA(H9)=1,IF(AX42=4,0,IF(AX42=0,0,\"共済番号の\")),\"\")","v":""},{"$f":"IF(COUNTA(H9)=1,IF(AX42=0,0,LOOKUP(AX42,AZ38:AZ44,AY38:AY44)),\"\")","v":""},{"$f":"IF(COUNTA(H9)=1,IF(AX42>0,\"を入力してください\",0),\"\")","v":""}]
[]
[null,null,null,"南信地域町村交通災害共済事務組合管理者　様"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"町村",null,null,null,null,null,null,null,"長",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"㊞"]
[]
[null,"組合使用欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"決定額",null,null,null,null,null,null,null,null,null,null,null,null,null,"円"]