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[{"$nulls":13},"育児休業手当金請求（変更請求）書",{"$nulls":55},"照　合",{"$nulls":5},"係"]
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[]
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[{"$nulls":53},"決 定 額",{"$nulls":7},"※"]
[{"$nulls":76},"円"]
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["組合員",{"$nulls":4},"記号番号",{"$nulls":18},"―",{"$nulls":15},"所属機関",null,null,null,"名　　称"]
[]
[]
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[{"$nulls":5},"氏名",{"$nulls":38},"所 在 地"]
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[]
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[null,"標準報酬\nの等級及び月額",{"$nulls":15},"　第○○級　○○○，○○○円","第",{"$nulls":5},"級",{"$nulls":12},"円",null,null,"育児休業手当金\nの 請 求 期 間",{"$nulls":13},"令和",{"$nulls":7},"年",{"$nulls":5},"月",{"$nulls":5},"日",null,"から"]
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[{"$nulls":54},"令和",{"$nulls":7},"年",{"$nulls":5},"月",{"$nulls":5},"日",null,"まで"]
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[null,"育児休業の初日",{"$nulls":16},"令和",{"$nulls":6},"年",{"$nulls":5},"月",{"$nulls":5},"日",null,null,"給 付 日 額\n(備考)３、４参照",{"$nulls":12},"　育児休業の初日から\n　１８０日まで（Ｂ１）",{"$nulls":13},"　１８１日以降（Ｂ２）"]
[{"$nulls":64},"円",{"$nulls":13},"円"]
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[null,"育児休業の末日",{"$nulls":16},"令和",{"$nulls":6},"年",{"$nulls":5},"月",{"$nulls":5},"日",null,null,"給 付 日 数",{"$nulls":12},"　育児休業の初日から\n　１８０日まで（Ｃ１）",{"$nulls":13},"　１８１日以降（Ｃ２）"]
[{"$nulls":64},"日",{"$nulls":13},"日"]
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[null,"育児休業に係る\n子の生年月日",{"$nulls":16},"令和",{"$nulls":6},"年",{"$nulls":5},"月",{"$nulls":5},"日",null,null,"請求金額（Ｄ３）\n(備考)５参照",{"$nulls":34},"円"]
[]
[]
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[{"$nulls":67},"請 求 回 数"]
[null,"育児休業手当金\n\n支給期間延長事由",{"$nulls":15}," １ 保育所における保育が実施されないこと"]
[{"$nulls":17}," ２ 養育を予定していた配偶者の死亡"]
[{"$nulls":17}," ３ 養育を予定していた配偶者の負傷・疾病等",{"$nulls":56},"回 目"]
[{"$nulls":17}," ４ 養育を予定していた配偶者との婚姻の解消等による別居"]
[{"$nulls":17}," ５ 養育を予定していた配偶者の産前産後休業等"]
[{"$nulls":17}," ６ 本請求とは別の子に係る産前産後休業を開始したことにより本請求に係る子につい\n　　ての育児休業を終了した場合で、当該産前産後休業に係る子の全てが死亡又は組合\n　　員と同居しないこととなったこと。"]
[]
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[{"$nulls":17}," ７ 介護休業を開始したことにより本請求に係る子についての育児休業を終了した場合\n　　で、当該介護休業に係る対象家族が死亡もしくは離婚等により組合員との親族関係\n　　が消滅したこと。"]
[]
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[{"$nulls":17}," ８ 本請求とは別の子に係る新たな育児休業を開始したことにより本請求に係る子につ\n　　いての育児休業を終了した場合で、当該新たな育児休業に係る子の全てが死亡又は\n　　組合員と同居しないこととなったこともしくは養子縁組等が成立しなかったこと。"]
[]
[]
[]
[]
[null,null,null,"上記のとおり請求します。"]
[]
[{"$nulls":5},"愛知県市町村職員共済組合理事長 様"]
[]
[{"$nulls":7},"令和　　 年　　 月　　 日"]
[]
[]
[{"$nulls":41},"住　所"]
[]
[{"$nulls":30},"請求者"]
[{"$nulls":41},"氏　名"]
[]
[]
[]
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[null,null,null,"上記の記載事項は、事実と相違ないものと認めます。"]
[]
[{"$nulls":7},"令和　　 年　　 月　　 日"]
[]
[]
[{"$nulls":41},"職　名"]
[]
[{"$nulls":30},"所属所長"]
[{"$nulls":41},"氏　名"]
[]
[]
[]
[]
["（備考）１　育児休業（又は変更）に関する所属機関の長の証明書を添付してください。"]
["　　　　２　勤務しなかった期間に報酬が支払われた場合は、支払われた報酬についての所属機関の長又は事務担当者の"]
["　　　　　証明書を添付してください。"]
["        ３　標準報酬の日額・・標準報酬の月額×１／２２（１０円未満四捨五入）…（Ａ）"]
["　　　　４　給付日額・・育児休業の初日から１８０日まで…（Ｂ１）\n　　　　　　　　    　　（Ｂ１）＝（Ａ）×６７／１００（円未満切捨て）上限額を超える場合は上限額　"]
[]
["　　　　　　　　　　　　１８１日以降…（Ｂ２）\n　　　　　　　　　　  　（Ｂ２）＝（Ａ）×５０／１００（円未満切捨て）上限額を超える場合は上限額　"]
[]
["　　　　５　請求金額・・育児休業の初日から１８０日まで…（Ｄ１）\n　　　　　　　 　 　　　（Ｄ１）＝（Ｂ１）×給付日数（Ｃ１）　"]
[{"$nulls":56},"合計額（Ｄ３）＝（Ｄ１）＋（Ｄ２）"]
["　　　　　　　　　　　　１８１日以降…（Ｄ２）\n　　　　　　　　　  　  （Ｄ２）＝（Ｂ２）×給付日数（Ｃ２）"]
[]
["　　　　※印欄は記入しないでください。"]