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[{"$nulls":9},"理事長",null,"常務理事",null,"担当"]
["貸付番号"]
["＊申込日","　　年　　月　 　日",null,null,"＊決定日",null,"　　年　　 月　　日"]
["＊出産資金貸付見込額",null,null,"500,000円×80％＝400,000円\n(488,000円×80％＝390,400円）",{"$nulls":5},"資格","取得"," 　年 　　月 　　日"]
[{"$nulls":10},"喪失"," 　年 　　月 　　日"]
["＊貸付決定額\n１０００円未満切り捨て",null,null,"　　　　　　　円",{"$nulls":5},"資　格\n該当者","取得"," 　年 　　月 　　日"]
[{"$nulls":10},"喪失"," 　年 　　月 　　日"]
[]
["出　産　費　資　金　貸　付　申　請　書"]
[]
["　　　１.貸付対象者(番号を○で囲んでください）"]
[]
[null,1,"出産予定日まで１ヶ月以内の被保険者"]
[null,2,"出産予定日まで１ヶ月以内の扶養家族を有する被保険者"]
[null,3,"妊娠４ヶ月以上の被保険者及び扶養家族で医療機関に一時的な支払が必要となった方"]
[]
["　　　２.下記内容をご記入ください"]
[]
[null,"被保険者の記号番号",null,"記号",{"$nulls":5},"番号"]
[null,"事業所の名称"]
[null,"事業所の住所"]
[null,"被保険者の氏名"]
[null,"分娩予定者",null,"氏名"]
[null,null,null,"生年月日",null,null,"Ｓ・Ｈ　　　年　　  月　 　日",{"$nulls":4},"続柄"]
[null,"該当医療機関"]
[null,"医療機関の所在地"]
[null,"支払予定額",null,"円"]
[null,"貸付希望金額",null,"円"]
[]
["　　　３.添付書類（下記書類を提出してください）"]
[]
[null,"●出産予定日まで１ヶ月以内の方"]
[null,1,"母子健康手帳の写し（表紙１ページ及び妊娠中の経過４．５ページ）、その他出産予定日まで１ヶ月以内であることの医師(助産師）の証明"]
[]
[null,2,"直接支払制度の合意文書（直接支払制度を利用しない旨の記載のあるもの）"]
[]
[null,"●妊娠４ヶ月以上の方で医療機関に一時的な支払が必要となった方"]
[null,1,"母子健康手帳の写し（表紙１ページ及び妊娠中の経過４．５ページ）、その他妊娠４ヶ月以上であることの医師(助産師）の証明"]
[]
[null,2,"直接支払制度の合意文書（直接支払制度を利用しない旨の記載のあるもの）"]
[null,3,"医療機関等からの出産に要する費用の明細のある請求書又は領収書"]
[]
["　　　4.振込先を記入してください"]
[]
[null,"振込先",null,null,"銀行\n金庫\n農協",null,null,"本店\n支店\n出張所","普通","口座番号   (                            )"]
[]
[{"$nulls":8},"口座名義   (                                    )"]
[]
[]
["　中部アイティ産業健康保険組合　理事長　殿",{"$nulls":8},"平成　　　年　　　月　　　日"]
[{"$nulls":5},"住所","〒　　　　-"]
[null,null,"被保険者"]
[{"$nulls":5},"自宅ＴＥＬ"]
[{"$nulls":5},"氏名"]
[{"$nulls":13},"2023年4月更新"]