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[null,"限度額適用・標準負担額減額認定申請書"]
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[null,null,"組合員",{"$nulls":13},"記号番号",{"$nulls":20},"－",{"$nulls":21},"所属所",{"$nulls":4},"名称"]
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[null,null,"組合員（減額該当者）の住所"]
[null,null,"長期入院",{"$nulls":12},"該当 ・ 非該当"]
[null,"①",null,null,null,"申請日の前１年間の入院期間（日数）",{"$nulls":42},"令和",{"$nulls":12},"年",{"$nulls":9},"月",{"$nulls":9},"日から",{"$nulls":14},"日間"]
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[{"$nulls":5},"入院をした保健医療機関等",{"$nulls":42},"名称"]
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[null,null,"市区町村長が証明する欄"]
[{"$nulls":30},"　当該組合員には、 　　 　　　年度の市（区）町村民税が"]
[{"$nulls":30},"課されないことを証明する。"]
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[{"$nulls":30},"　　　令和　　　年　　　月　　　日"]
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[{"$nulls":49},"市区町村長名"]
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[{"$nulls":8},"上記のとおり申請します。"]
[{"$nulls":8},"　愛知県市町村職員共済組合理事長 様"]
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[{"$nulls":8},"　　令和　　　年　　　月　　　日"]
[{"$nulls":49},"住所"]
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[{"$nulls":38},"申請者"]
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[{"$nulls":49},"氏名"]
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[{"$nulls":8},"上記の記載事項は、事実と相違ないものと認めます。"]
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[{"$nulls":8},"　　令和　　　年　　　月　　　日"]
[{"$nulls":49},"職名"]
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[{"$nulls":38},"所属所長"]
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["※",null,null,"　市区町村長が証明する欄にて証明を受けられない場合は、組合員に係る「市町村民税非課税証明書」又は共済組合が情報提供ネットワークシステムを使用して、組合員の課税状況を照会することの「同意書」を添付してください。"]