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[{"$nulls":34},"（様式例2）"]
["健　康　保　険　　　　　　　　厚生年金保険",{"$nulls":5},"被保険者報酬月額算定基礎届・保険者算定申立に係る例年の状況、\n標準報酬月額の比較及び被保険者の同意等"]
[]
[]
[]
["【申請にあたっての注意事項】"]
[null,"・","この用紙は、算定基礎届をお届けいただくにあたって、年間報酬の平均で決定することを申し立てる場合に必ず提出してください。"]
[null,"・","この用紙は、定時決定にあたり、４、５、６月の報酬の月平均と年間報酬の月平均に２等級以上差があり、年間報酬の平均で決定"]
[null,null,"することに同意する方のみ記入してください。"]
[null,"・","また、被保険者の同意を得ている必要がありますので、同意欄に被保険者の自署にて氏名を記入いただくか記名のうえ押印"]
[null,null,"してください。"]
[null,"・","なお、標準報酬月額は、年金や傷病手当金など、被保険者が受ける保険給付の額にも影響を及ぼすことにご留意下さい。"]
[]
[]
["事業所整理記号",{"$nulls":15},"事業所名称"]
[]
[]
[]
["被 保 険 者 整 理 番 号",{"$nulls":8},"被 保 険 者 の 氏 名",{"$nulls":12},"生　年　月　日",{"$nulls":11},"種別"]
[]
[]
[]
[]
["【前年７月～当年６月の報酬額等の欄】"]
["算定基礎月の報酬支払基礎日数",{"$nulls":10},"通貨によるものの額",{"$nulls":8},"現物によるものの額",{"$nulls":8},"合計"]
["令和",null,null,"年",7,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",8,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",9,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",10,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",11,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",12,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",1,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",2,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",3,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",4,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",5,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
["令和",null,null,"年",6,"月",{"$nulls":3},"日",{"$nulls":8},"円",{"$nulls":8},"円",{"$nulls":8},"円"]
[]
["【標準報酬月額の比較欄】※全て事業主が記載してください。"]
["従前の\n標準報酬月額",{"$nulls":5},"健　康　保　険",{"$nulls":7},"厚 生 年 金 保 険"]
[{"$nulls":12},"千円",{"$nulls":7},"千円"]
[]
[]
["前年7月～本年6月の\n合計額",{"$nulls":7},"前年7月～本年6月の\n平均額",{"$nulls":7},"健　康　保　険",{"$nulls":10},"厚 生 年 金 保 険"]
[{"$nulls":16},"等級",{"$nulls":3},"標準報酬月額",{"$nulls":6},"等級",{"$nulls":3},"標準報酬月額"]
[{"$nulls":6},"円",{"$nulls":7},"円",{"$nulls":10},"千円",{"$nulls":10},"千円"]
[]
[]
["本年4月～6月の\n合計額",{"$nulls":7},"本年4月～6月の\n平均額",{"$nulls":7},"健　康　保　険",{"$nulls":10},"厚 生 年 金 保 険"]
[{"$nulls":16},"等級",{"$nulls":3},"標準報酬月額",{"$nulls":6},"等級",{"$nulls":3},"標準報酬月額"]
[{"$nulls":6},"円",{"$nulls":7},"円",{"$nulls":10},"千円",{"$nulls":10},"千円"]
[]
[]
["２等級以上（○又は×）",{"$nulls":3},"修　正　平　均　額",{"$nulls":11},"健　康　保　険",{"$nulls":10},"厚 生 年 金 保 険"]
[{"$nulls":16},"等級",{"$nulls":3},"標準報酬月額",{"$nulls":6},"等級",{"$nulls":3},"標準報酬月額"]
[{"$nulls":14},"円",{"$nulls":10},"千円",{"$nulls":10},"千円"]
[]
[]
["【被保険者の同意欄】"]
[]
["私は本年の定時決定にあたり、年間報酬額の平均で決定することを希望しますので、当事業所が申立てすることに同意します。"]
[]
[{"$nulls":16},"被保険者氏名"]
[]
[]
["【備考欄】"]