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[]
[null,"介護保険高額介護（居宅支援）サービス費支給申請書"]
[]
[]
[null,"ﾌﾘｶﾞﾅ",null,null,null,null,{"$f":"PHONETIC(G6)","v":""},null,null,null,null,null,null,null,null,null,null,null,"保険者番号",null,null,null,null,null,null,null,null,4,0,6,2,5,6]
[null,"被保険者\n氏名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者番号"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,"生年月日",null,null,null,null,"大　･ 昭　　　　　年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,"性　　別",null,null,null,null,"　男　　・　　女"]
[null,"住　　　所",null,null,null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[null,null,null,null,null,null,"氏　　　名",null,null,null,null,null,null,null,"生年月日"]
[null,"世帯構成","世帯主",null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,"世帯員",null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[]
[null,null,"みやこ町長　　様"]
[]
[null,null,"上記のとおり高額介護（居宅支援）サービス費の支給を申請します。"]
[]
[]
[null,null,null,null,null,null,"年　　　　",null,null,"月",null,null,"日"]
[]
[]
[null,null,"届出者",null,null,null,"住　所"]
[]
[null,null,null,null,null,null,"氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,"（本人との関係：　　　　　）"]
[]
[null,null,null,null,null,null,"電話番号"]
[]
[]
[]
[null,"注意　",null,"　・初回申請時より２年以上前の高額介護サービス費については請求権が時効消滅しています。"]
[null,null,null,"　・給付制限を受けている方については、高額介護（居宅支援）サービス費の支給ができない場合があります。"]
[null,null,null,"　・振込口座の変更を希望する場合は届出してください。"]
[]
[]
[]
[null,"口座振替\n依頼欄",null,null,"銀     行\n農　　 協",null,null,null,null,null,null,null,null,null,null,null,"本  店",null,null,null,null,null,"種　　目",null,null,null,"口座番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"支  店"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"支　所"]
[null,null,null,null,"金融機関コード",null,null,null,null,null,null,null,null,null,null,null,"店舗コード",null,null,null,null,null,"１・普通預金"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２・当座預金"]
[null,null,null,null,"口座名義カナ"]
[]
[]
[null,"市町村記入欄"]
["区分",null,null,"給付制限",null,null,null,null,"（市町村民税課税状況等）（平成　　　年　　　月　　　日現在）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"利用者負担段階"]
[null,null,null,"状　　　況",null,null,null,null,"□市町村民税課税世帯"]
["単独\n\n合算",null,null,"償　　還",null,null,null,null,"□市町村民税非課税世帯",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"段階"]
[null,null,null,"差　　止",null,null,null,null,null,"□８０万円超　　　　□８０万円以下等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"口座登録"]
[null,null,null,"給付率",null,null,null,null,null,"□老齢福祉年金受給者"]
[null,null,null,"無　　し",null,null,null,null,"□その他（境界層）"]
[null,"※添付書類"]
[]
[null,"□　通帳の写し"]

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["記入例"]
[]
[]
[null,"介護保険高額介護（居宅支援）サービス費支給申請書"]
[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,"被保険者氏名を記入してください。"]
[]
[null,"ﾌﾘｶﾞﾅ",null,null,null,null,"ミヤコ　タロウ",null,null,null,null,null,null,null,null,null,null,null,"保険者番号",null,null,null,null,null,null,null,null,4,0,6,2,5,6]
[null,"被保険者\n氏名",null,null,null,null,"みやこ　太郎　　　"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者番号",null,null,null,null,1,2,3,4,5,6,7,8,0,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"認印を必ず押して下さい。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,"生年月日",null,null,null,null,"　大　･ 　　　　　10年　1月　1日",null,null,null,null,null,null,null,null,null,null,null,"性　　別",null,null,null,null,"　　　・　　女"]
[null,"住　　　所",null,null,null,null,"〒","824-0892　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　みやこ町勝山上田960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,"32-2516",null,null,null,null,null,null,null,null,"連絡のつく電話番号を　　　お願いします。"]
[null,null,null,null,null,null,"氏　　　名",null,null,null,null,null,null,null,"生年月日"]
[null,"世帯構成","世帯主",null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者ご本人の口座を　記入して下さい。"]
[null,null,"世帯員",null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大 ･ 昭　　　　年　　　月　　　日",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人番号"]
[]
[null,null,"みやこ町長　　様"]
[]
[null,null,"上記のとおり高額介護（居宅支援）サービス費の支給を申請します。"]
[]
[]
[null,null,"令和",null,null,null,"年　　　　",null,null,"月",null,null,"日"]
[]
[]
[null,null,"届出者",null,null,null,"住　所",null,null,null,"みやこ町勝山上田960番地"]
[]
[null,null,null,null,null,null,"氏　名",null,null,null,"みやこ　花子",null,null,null,null,null,null,null,null,null,"（本人との関係：　妻　　　）"]
[]
[null,null,null,null,null,null,"電話番号",null,null,null,"32-2516"]
[]
[]
[null,"注意　",null,"　・初回申請時より２年以上前の高額介護サービス費については請求権が時効消滅しています。"]
[null,null,null,"　・給付制限を受けている方については、高額介護（居宅支援）サービス費の支給ができない場合があります。"]
[null,null,null,"　・振込口座の変更を希望する場合は届出してください。"]
[]
[]
[]
[null,"口座振替\n依頼欄",null,null,"みやこ　　　　　　銀     行\n農　　 協",null,null,null,null,null,null,null,null,null,null,null,"本  店",null,null,null,null,null,"種　　目",null,null,null,"口座番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　　　　　みやこ　　　　　支  店"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"支　所"]
[null,null,null,null,"金融機関コード",null,null,null,null,null,null,null,null,null,null,null,"店舗コード",null,null,null,null,null,"①普通預金",null,null,null,0,1,2,3,4,5,6]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２・当座預金"]
[null,null,null,null,"口座名義カナ",null,null,null,null,null,null,null,null,null,null,null,"ミヤコ　タロウ"]
[]
[]
[null,"市町村記入欄"]
["区分",null,null,"給付制限",null,null,null,null,"（市町村民税課税状況等）（平成　　　年　　　月　　　日現在）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"利用者負担段階"]
[null,null,null,"状　　　況",null,null,null,null,"□市町村民税課税世帯"]
["単独\n\n合算",null,null,"償　　還",null,null,null,null,"□市町村民税非課税世帯",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"段階"]
[null,null,null,"差　　止",null,null,null,null,null,"□８０万円超　　　　□８０万円以下等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"口座登録"]
[null,null,null,"給付率",null,null,null,null,null,"□老齢福祉年金受給者"]
[null,null,null,"無　　し",null,null,null,null,"□その他（境界層）"]
[null,"※添付書類"]
[]
[null,"□　通帳の写し"]