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[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和 　　　　　年　　　　　月　　　　　日"]
[]
["み や こ 町 長　殿"]
[]
[]
[null,null,null,"住　　所",null,null,"みやこ町",null,null,null,null,null,null,null,"請求印"]
[]
[null,null,null,"氏　　名"]
[]
[null,null,null,"生年月日（T　S　H　Ｒ )　　　　　年　　　　月　　　　日"]
[]
[null,null,null,"電話番号"]
[]
[]
[]
[null,null,"月分　健康管理用血圧計購入費補助金として"]
[]
[null,"金",null,null,null,null,null,null,null,null,null,"　円を請求します。"]
[]
["◇","請求の根拠"]
[]
[null,null,"平成・令和　  　　年　  　　月購入分 健康管理用血圧計購入補助金"]
[]
[]
["◇","支払先"]
[]
[null,null,"金融機関名",null,null,null,null,null,null,"銀行\n農協\n金庫",null,null,null,null,"支店\n支所"]
[null,null,"種　　　別",null,null,"普通　・　当座"]
[null,null,"口座番号"]
[null,null,"ふりがな"]
[null,null,"口座名義人"]