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[]
[null,"　健康保険 出産手当金 支給申請書"]
[]
[]
[]
[]
[]
[null,"被保険者（申請者）情報",null,"被保険者記号 番号（右づめ）",null,null,null,"記号",null,null,null,null,null,null,"番号",null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[]
[]
[]
[null,null,null,"氏名",null,null,"(ﾌﾘｶﾞﾅ)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日は令和5年1月3日生まれの方は、05　01　03　とご記入下さい。"]
[]
[]
[null,null,null,"住所",null,null,"〒",null,null,"ー"]
[]
[]
[null,null,null,"電話番号",null,null,"TEL",null,null,null,null,null,null,"（",null,null,null,null,"）"]
[null,null,null,"(日中の連絡先)"]
[]
[null,"事業主記入欄",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,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,"　事業所所在地"]
[null,null,null,"〒",null,null,"ー"]
[]
[]
[null,null,null,"   事業所名称",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"      事業主氏名"]
[]
[]
[]
[null,null,null,"TEL",null,null,null,"（",null,null,"）"]
[]
[]
[]
[null,null,null,null,null,"この届出については、記載内容について誤りがないか事業主が"]
[null,null,null,null,null,"確認している。"]
[]
[]
[]
[]
[]
[null,null,"※　□　確認している場合は、レ点チェックをして下さい。"]
[]
[null,null,"※　資格喪失後の支給分については、別紙　振込先指定口座の用紙を",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,"受付日付印"]
[null,null,null,"  提出して下さい。"]
[null,null,"　　"]
[null,null,"※　記入漏れ等、不備がありましたら返却させて頂きます。"]
[null,null,"　　それに伴い、給付金のお支払いも遅れる場合がありますのでご了解願います。"]
[null,null,"社会保険労務士の　　提出代行者名記載欄"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"報徳同栄健康保険組合"]
[]
[]
[]
[]
[]
[]
[]
[null,null,"　　"]

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[]
["　","健康保険 出産手当金 支給申請書"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["申請内容",null,null,"今回の出産手当金の申請は、出産前の申請ですか、　　　　　　　　　それとも出産後の申請ですか"]
[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,"1．出産前の申請",null,null,null,null,null,null,null,"2．出産後の申請"]
[]
[]
[]
[null,null,null,"上記で｢出産前の申請｣の場合は、出産予定日をご記入ください。　　　　｢出産後の申請｣の場合は、出産日と出産予定日をご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"出産予定日",null,null,null,null,null,"令和",null,null,null,"年",null,null,"月",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,null,null,null,null,"出 産 日",null,null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,null,null,"出産のために休んだ期間(申請期間)",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,"令和",null,null,null,"年",null,null,"月",null,null,"日から",null,null,null,null,null,null,null,"日間"]
[]
[]
[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,"令和",null,null,null,"年",null,null,"月",null,null,"日まで"]
[]
[]
[null,null,null,"上記の出産のため休んだ期間(申請期間)の報酬を受けましたか。   　または今後受けられますか。"]
[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,"1．はい",null,null,null,null,"2．いいえ"]
[]
[]
[]
[null,null,null,"上記で｢はい｣と答えた場合、その報酬の額と、その報酬支払の　 　　基礎となった(なる)期間をご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日から",null,null,null,null,null,null,null,"日間"]
[]
[]
[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,"令和",null,null,null,"年",null,null,"月",null,null,"日まで"]
[]
[]
[null,null,null,"出生児の数"]
[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,"単胎",null,null,null,null,null,null,"多胎(",null,null,null,null,null,"児)"]
[]
[]
[]
[null,null,"　　"]
[]
["医師・助産師記入欄",null,"出産者氏名"]
[]
[]
[]
[null,null,"出産予定年月日",null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,"月",null,null,"日",null,null," 出産年月日",null,null,null,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[null,null,"出生児の数",null,null,null,null,null,null,null,null,null,null,null,null,"単胎",null,null,null,"多胎(",null,null,null,null,"児)",null,null,"生産または死産の別",null,null,null,null,null,null,null,null,null,null,null,null,"生産",null,null,null,"死産(妊娠",null,null,null,null,null,null,"週)"]
[]
[]
[]
[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,"令和",null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[]
[]
[]
[null,null," 医療施設の所在地"]
[]
[]
[]
[null,null," 医療施設の名称"]
[]
[]
[]
[null,null," 医師・助産師の氏名",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,"TEL",null,null,null,null,null,"(",null,null,null,null,")"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"報徳同栄健康保険組合"]

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[]
[null,"   健康保険 出産手当金 支給申請書"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"労務に服さなかった期間を含む賃金計算期間の勤務状況および賃金支払状況等をご記入ください。"]
["事業主が証明するところ",null,"被保険者氏名"]
[]
[]
[null,null,"勤務状況　【出勤は〇】【有給は△】【公休は公】【欠勤は／】でそれぞれ表示してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"出勤",null,null,null,"有給"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]
[]
[null,null,"令和",null,null,null,null,"年",null,null,"月",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,"　　計",null,null,{"$f":"COUNTIF(M20:AQ21,\"○\")","v":0},null,null,"日",{"$f":"COUNTIF(M20:AQ21,\"△\")","v":0},null,null,"日"]
[]
[null,null,"令和",null,null,null,null,"年",null,null,"月",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,"　　計",null,null,{"$f":"COUNTIF(M22:AQ23,\"○\")","v":0},null,null,"日",{"$f":"COUNTIF(M22:AQ23,\"△\")","v":0},null,null,"日"]
[]
[null,null,"令和",null,null,null,null,"年",null,null,"月",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,"　　計",null,null,{"$f":"COUNTIF(M24:AQ25,\"○\")","v":0},null,null,"日",{"$f":"COUNTIF(M24:AQ25,\"△\")","v":0},null,null,"日"]
[]
[null,null,"令和",null,null,null,null,"年",null,null,"月",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,"　　計",null,null,{"$f":"COUNTIF(M26:AQ27,\"○\")","v":0},null,null,"日",{"$f":"COUNTIF(M26:AQ27,\"△\")","v":0},null,null,"日"]
[]
[null,null,"令和",null,null,null,null,"年",null,null,"月",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,"　　計",null,null,{"$f":"COUNTIF(M28:AQ29,\"○\")","v":0},null,null,"日",{"$f":"COUNTIF(M28:AQ29,\"△\")","v":0},null,null,"日"]
[]
[null,null,"上記の期間に対して、賃金を     　　支給しました（します）か？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"給与の種類",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"賃金計算",null,null,null,null,"締　日",null,null,"末",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,"月給",null,null,null,null,"時間給"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"は　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,null,null,null,null,null,"日給",null,null,null,null,"歩合給"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"いいえ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"支払日",null,null,null,null,"当月",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,"日給月給",null,null,null,null,"その他"]
[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,null,null,"翌月"]
[]
[null,null,"上記の期間を含む賃金支給状況をご記入ください。"]
[]
[]
[null,null,"支給した(する)賃金内訳",null,null,null,null,null,null,null,"単価",null,null,null,null,null,null,null,"月",null,null,"日～",null,null,null,null,"月",null,null,"日～",null,null,null,null,"月",null,null,"日～",null,null," 賃金計算方法(欠勤控除計算方法等)     　についてご記入ください。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,"日分",null,null,null,null,"月",null,null,"日分",null,null,null,null,"月",null,null,"日分"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"支給額",null,null,null,null,null,null,null,"支給額",null,null,null,null,null,null,null,"支給額"]
[]
[null,null,null,null," 基本給"]
[]
[null,null,null,null," 通勤手当"]
[]
[null,null,null,null," 住居手当"]
[]
[null,null,null,null," 扶養手当"]
[]
[null,null,null,null,"手当"]
[]
[null,null,null,null,"手当"]
[]
[null,null,null,null," 現物給与"]
[]
[null,null,null,null,"計",null,null,null,null,null,{"$f":"SUM(K47:P60)","v":0},null,null,null,null,null,{"$f":"SUM(Q47:X60)","v":0},null,null,null,null,null,null,null,{"$f":"SUM(Y47:AF60)","v":0},null,null,null,null,null,null,null,{"$f":"SUM(AG47:AN60)","v":0}]
[]
[null,null,"上記のとおり相違ないことを証明する。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,"担当者氏名"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"〒",null,null,null,"ー"]
[null,null,"事業所所在地"]
[]
[]
[null,null,"事業所名称"]
[]
[]
[null,null,"事業主氏名",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,"TEL",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,"【被保険者の方へ】"]
[]
[]
[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,"❶",null,"お勤め先の事業所から証明を受けてください。資格喪失日以降の　　　   　　   期間に関する申請については、空欄でご提出ください。"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【療養担当の方へ】"]
[]
[]
[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,"➋",null,"労務に服さなかった期間を含む賃金計算期間                                                (賃金計算の締日の翌日から締日の期間)の勤務状況について,                        出勤した場合は〇で、有給の場合は△で、公休日であれば公で、　　　　　      欠勤した場合は／で表示してください。"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"❸",null,"給与の種類について、該当する給与の種類を選んでください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➍",null,"賃金計算の締日および賃金の支払日をご記入ください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➎",null,"労務に服することができなかった期間を含む賃金計算期間に　　    　　            おける賃金支給状況についてご記入ください。　　　　　　　　　　                また、賃金支給状況がわかるよう、賃金計算方法や欠勤控除計算方法等を　   ご記入ください。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"報徳同栄健康保険組合"]

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["昭和","都",1,"○"]
["平成","道",2,"△"]
["令和","府",null,"公"]
[null,"県",null,"／"]