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[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,"年",null,null,null,"月",null,null,null,"日"]
["一般社団法人香川県中小企業退職金共済会　御中"]
[]
["退職金共済給付金請求書"]
[]
[]
[null,null,null,null,null,null,null,"退職金制度に関し、下記のとおり被共済者が受給権を取得しましたので規約に定める金額を請求いたします。"]
[]
["○共済契約者記入欄○"]
[]
[null,"共　済　契　約　番　号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被共済者番号",null,null,null,null,null,null,null,"被　共　済　者　氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,"生　年　月　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,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,"請　　求　　事　　由"]
[null,null,null,null,null,null,null,null,null,null,null,"１．退職",null,null,null,null,null,"２．死亡退職",null,null,null,null,null,null,null,"３．その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["住　　所",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,"押印（登録印）"]
[]
[]
["事業所名"]
[]
[]
["代表者名"]
[]
[]
[]
["○受取人記入欄○"]
[]
["住　　所",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,"-"]
[]
[]
["氏　　名"]
[]
[]
["振込先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"銀行",null,"・","信用金庫",null,null,null,"・","信用組合",null,null,null,"・","農協",null,null,null,null,null,null,null,null,null,null,null,"本店",null,"・","支店",null,"・","支所",null,"・","出張所"]
[]
[]
["種　　目",null,null,null,null,null,"口　座　番　号"]
["１．普通"]
["２．当座"]
["口座名義",null,null,null,null,null,"フリガナ"]
[]
[null,null,null,null,null,null,"漢　字"]
[]
[]
[]
[]
["※　退職金共済証を必ずご提出ください（もし、紛失された場合は次頁の念書にご記入ください）。"]
["※　次頁の『手続き上のご留意点』をよくお読みのうえ、はっきりとご記入・押印ください。記入漏れ"]
["　　添付書類の不備等がありますと、支給が遅れることもありますのでご注意ください。"]
["～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～"]
["◆◆◆　共済会使用欄　◆◆◆"]
[]
[null,null,null,null,"加入年月",null,null,null,null,"最終年月",null,null,null,null,"最終口数",null,null,null,null,null,null,null,null,null,null,null,"提　出　日",null,null,null,null,null,"請求書",null,null,null,"申告書",null,null,null,"共済証・念書",null,null,null,"個人番号",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,"・",null,null,null,null,"・",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"最終入金日",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",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,"受　付　日",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["事務局長",null,null,null,"課　長",null,null,null,"検　印",null,null,null,"入力者印",null,null,null,"照合者印",null,null,null,"担当者印",null,null,null,null,null,"支　払　日",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",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,"給付金額"]
[]
[]
[]
["※Ⅰ　退職金共済証を紛失された方は下記の念書に、ご記入のうえ、ご提出下さい。"]
[]
["～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～"]
[]
["一般社団法人香川県中小企業退職金共済会　御中"]
[]
[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,"受取人"]
[]
[]
[]
[]
["念　　　書"]
[null,null,null,null,null,null,null,"給付金の請求にあたり退職金共済証を添付すべきところ、紛失のため提出できません。"]
[null,null,null,null,null,null,null,"紛失した退職金共済証が見つかった場合は、即刻返還いたしますとともに、本件につい"]
[null,null,null,null,null,null,null,"て紛議等が生じましても、私が一切の責任を負い、貴共済会に対し何らご迷惑をおかけ"]
[null,null,null,null,null,null,null,"致しません。"]
[]
[]
[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,"以　上"]
[]
["～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～"]
["◆手続き上のご留意点◆"]
[]
[null,null,"必　要　書　類",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退職",null,null,"死亡",null,null,"解約",null,null,null,"①","手続き書類一覧表（左記参照）"]
[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,"②","給付金のご請求は被共済者→事業主→香中退共あてと"]
[null,null,"退職金共済給付金請求書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○",null,null,"○",null,null,"○",null,null,null,null,"なります。"]
[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,"③","共済契約番号、被共済者番号はご加入時に発行した退"]
[null,null,"退職所得申告書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○",null,null,"－",null,null,"－",null,null,null,null,"職金共済証をご参照ください。"]
[]
[null,null,"退職金共済証(注1)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○",null,null,"○",null,null,"○",null,null,null,"(注1)　退職金共済証を紛失された場合は、上記の念書にご記"]
[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,"　　　 入ください。"]
[null,null,"被共済者の除籍謄本（または抄本）",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,null,"(注2)　被共済者の除籍謄本中に受給権者の記載がある場合、"]
[null,null,"受給権者の戸籍謄本（または抄本）(注2)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"－",null,null,"○",null,null,"－",null,null,null,"　　　 受給権者の戸籍謄本は不要になります。"]
[]
[null,null,"被共済者の解約同意書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"－",null,null,"－",null,null,"○",null,null,null,"(注3)　個人番号(マイナンバー)確認書類は下記表のいずれか"]
[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,"       をご用意ください。"]
[null,null,"個人番号(マイナンバー)確認書類（注3）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○",null,null,"○※1",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　",null,"死亡の場合は、遺族受取人様の確認書類が必要。"]
[]
[]
[]
[null,null,"個人番号（マイナンバー）確認のために必要な書類"]
[null,null,"次のいずれかの書類"]
[null,null,"①",null,"個人番号カードの写し（個人番号が記載された面）"]
[null,null,"②",null,"通知カードの写し（個人番号が記載された面）"]
[null,null,"③",null,"個人番号が記載された住民票の写し又は住民票記載事項証明書の写し"]
[]
["～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～～"]
[]
[null,null,"一般社団法人香川県中小企業退職金共済会"]
[null,null,"〒769-0104　香川県高松市国分寺町新名419番地2"]
[null,null,"℡（087）814-4311"]
[]
[]
[null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,"年分",null,"　退職所得の受給に関する申告書　兼　退職所得申告書"]
[null,null,null,"高松　税務署長　殿　／高松　市町村長　殿"]
[]
[null,null,null,"退職手当の支払者の",null,"所 在 地　　　(住 所）　",null,null,null,"〒769-0104",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"あなたの",null,"現 住 所",null,null,null,"〒",{"$f":"H29&\"\"","v":""},null,null,"－",{"$f":"L29&\"\"","v":""}]
[null,null,null,null,null,null,null,null,null,"高松市国分寺町新名419番地2",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"G30&\"\"","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏　　名",null,null,null,{"$f":"G32&\"\"","v":""}]
[null,null,null,null,null,"名   　称　　　　　(氏 名）",null,null,null,"一般社団法人　香川県中小企業退職金共済会"]
[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,"個人番号"]
[]
[null,null,null,null,null,"法人番号\n(個人番号）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その年1月1日\n現在の住所",null,null,null,"同上"]
[]
[]
[null,null,null,"A",null,"　　このA欄には、全ての人が、記載してください。（あなたが、前に退職手当等の支払を受けたことがない場合には、下のB以下の各欄には記載する必要がありません。）"]
[]
[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,"③","　この申告書の提出先から受ける退職手当等についての勤続期間",null,null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,"①","　退職手当等の支払を受けることと",null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,null,"至",{"$f":"R138&\"\"","v":""},null,null,"年",{"$f":"U138&\"\"","v":""},null,"月",{"$f":"X138&\"\"","v":""},null,"日"]
[null,null,null,null,null,null,"なった年月日"]
[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,"うち　特定役員等勤続期間",null,null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,"退職の区分等",null,null,null,null,null,null,"＜一般・障害の区分＞",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,"至",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,"うち　一般勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"一般",null,"・","障害",null,null,null,null,null,null,null,null,null,null,null,null,"との重複勤続期間",null,null,null,null,null,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"うち　短期勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"＜生活扶助の有無＞",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"との重複勤続期間",null,null,null,null,null,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,"・","無",null,null,null,null,null,null,null,null,null,null,null,"うち　短期勤続期間",null,null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[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,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,"B",null,"　　あなたが本年中に他にも退職手当等の支払を受けたことがある場合には、このB欄に記載してください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自",null,null,"年",null,null,"月",null,null,"日","⑤","③と④の通算勤続期間",null,null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,"④","　本年中に支払を受けた他の退職手当等についての勤続期間",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,null,"至",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,"至",null,null,"年",null,null,"月",null,null,"日",null,"うち　特定役員等勤続期間",null,null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[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,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,null,"うち　特定役員等勤続期間",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"うち　一般勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,"自",null,null,"年",null,"月",null,"日",null,null,null,null,"との重複勤続期間",null,null,null,null,null,"無",null,"至",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,"うち　短期勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,"との重複勤続期間",null,null,null,null,null,"無",null,"至",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,"うち　全重複勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,"うち　短期勤続期間",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,"無",null,"至",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,"有",null,"自",null,null,"年",null,"月",null,"日",null,null,null,"うち　短期勤続期間",null,null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[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,"無",null,"至",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,"無",null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,"うち　一般勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[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,"との重複勤続期間",null,null,null,null,null,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,"C",null,"　　あなたが前年以前4年内（その年に確定拠出年金法に基づく老齢給付金として支給される一時金の支払を受ける場合には、19年内）に退職手当等の支払"]
[null,null,null,null,null,"　を受けたことがある場合には、このC欄に記載してください。"]
[null,null,null,null,null,"⑥","　前年以前4年内（その年に確定拠出年金法に基づく老齢給付金として支給される一時金の支払を受ける場合には、19年内）の退職手当等についての勤続期間",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⑦","③又は⑤の勤続期間のうち、⑥",null,null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自",null,null,"年",null,null,"月",null,null,"日",null,"の勤続期間と重複している期間",null,null,null,null,null,null,null,null,"至",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,"㋑","うち　特定役員等勤続",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,"年",null,null,"月",null,null,"日",null,null,"期間との重複勤続期間",null,null,null,null,null,"無",null,"至",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,"㋺","うち　短期勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[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,"との重複勤続期間",null,null,null,null,null,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,"D",null,"　　A又はBの退職手当等についての勤続期間のうちに、前に支払を受けた退職手当等についての勤続期間の全部又は一部が通算されている場合"]
[null,null,null,null,null,"　には、その通算された勤続期間等について、このD欄に記載してください。"]
[null,null,null,null,null,"⑧","　Aの退職手当等についての勤続期間（③）に通算された前の退職手当等についての勤続期間",null,null,null,null,null,null,null,null,null,null,"自",null,null,"年",null,"月",null,"日",null,"年","⑩","　③又は⑤の勤続期間のうち、⑧又は⑨の勤続期間だけからなる部分の期間",null,null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,null,null,null,null,"うち　特定役員等勤続期間",null,null,null,null,null,null,null,"有",null,"自",null,null,"年",null,"月",null,"日",null,"年",null,"㋩","うち　特定役員等勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,null,null,"うち　短期勤続期間",null,null,null,null,null,null,null,"有",null,"自",null,null,"年",null,"月",null,"日",null,"年",null,"㋥","うち　短期勤続期間",null,null,null,null,null,"有",null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,"⑨","　Bの退職手当等についての勤続期間（④）に通算された前の退職手当等についての勤続期間",null,null,null,null,null,null,null,null,null,null,"自",null,null,"年",null,"月",null,"日",null,"年","⑪","⑦と⑩の通算期間",null,null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,null,null,null,null,"うち　特定役員等勤続期間",null,null,null,null,null,null,null,"有",null,"自",null,null,"年",null,"月",null,"日",null,"年",null,"㋭","うち　㋑と㋩の通算期間",null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,null,null,"うち　短期勤続期間",null,null,null,null,null,null,null,"有",null,"自",null,null,"年",null,"月",null,"日",null,"年",null,"㋬","うち　㋺と㋥の通算期間",null,null,null,null,null,null,null,"自",null,null,null,"年",null,null,"月",null,null,"日",null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,"至",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,"至",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,"E",null,"　B又はCの退職手当等がある場合には、このE欄にも記載してください。"]
[null,null,null,null,null,"区分",null,null,"退職手当等の支払を受けることとなった年月日",null,null,null,null,"収　入　金　額",null,null,null,null,null,null,"源　　　　　　泉",null,null,null,null,"特別徴収税額",null,null,null,null,null,null,null,"支払を　　　　受けた　　　　年月日",null,null,null,"退職　　の　　区分",null,"支払者の所在地　　　　　　　　　　　\n(住所）・名称（氏名）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"徴　収　税　額",null,null,null,null,"市町村民税",null,null,null,"道府県民税"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"(円）",null,null,null,null,null,null,"(円）",null,null,null,null,"(円）",null,null,null,"(円）"]
[null,null,null,null,null,"Ｂ","一般",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,"一般"]
[]
[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,"障害"]
[null,null,null,null,null,null,"特定",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,"一般"]
[]
[null,null,null,null,null,null,"役員",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,"障害"]
[null,null,null,null,null,null,"短期",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,"一般"]
[]
[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,"障害"]
[null,null,null,null,null,"Ｃ",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,"一般"]
[]
[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,"障害"]
[null,null,null,"03.12改正",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,"（規格Ａ４）"]
["注　意　事　項"]
[]
["１",null,"　この申告書は、退職手当等の支払を受ける際に支払者に提出してください。提出しない場合は、所得税及び復興特別所得税の源泉徴収税額は、支"]
[null,null,"払を受ける金額の20.42％に相当する金額となります。また、市町村民税及び道府県民税については、延滞金を徴収されることがあります。"]
["２",null,"　Ｂの退職手当等がある人は、その退職手当等についての退職所得の源泉徴収票(特別徴収票)又はその写しをこの申告書に添付してください。"]
["３",null,"　支払を受けた退職手当等の金額の計算の基礎となった勤続期間に特定役員等勤続期間及び短期勤続期間が含まれる場合は、その旨並びに特定役員"]
[null,null,"等勤続期間、短期勤続期間、年数及び収入金額等を所定の欄に記載してください。"]
[]
["申 告 書 の 書 き 方"]
[]
[]
["１",null,"「①」欄には、退職年月日（会社の役員等の退職手当等で、株主総会等の決議を要するものは、その決議により支払を受ける金額が具"]
[null,null,"体的に定められた年月日）を記載します。"]
["２",null,"「②」欄には、在職中に障害者となったことに直接基因して退職した人は､｢障害」を○で囲み、( )内に障害の状態、身体障害者手帳"]
[null,null,"等の交付年月日等を記載します。その他の人は「一般」を○で囲みます。また、その年１月１日現在で生活保護法による生活扶助を受"]
[null,null,"けている人は、生活扶助の「有」を、その他の人は「無」を○で囲みます。"]
["３",null,"「③」欄には、この申告書を提出して今回支払を受ける退職手当等についての勤続期間とその年数(１年未満の端数は切上げ）を記載"]
[null,null,"します。"]
[null,null,"　この場合、勤続期間は、原則としてその支払者の下で引き続き勤務した期間（その支払者から前に退職手当等の支払を受けている場"]
[null,null,"合には、前の退職手当等の計算の基礎となった勤続期間の末日以前の期間を除きます。）によります。ただし、次の期間がある場合に"]
[null,null,"は、その期間を加えた期間によります。"]
[null,null,"(1)",null,"その支払者から受けた前の退職手当等の計算の基礎となった勤続期間で、今回の退職手当等の計算の基礎となる勤"]
[null,null,null,null,"続期間に通算された期間"]
[null,null,"(2)",null,"一時他に勤務していたなどのため、その支払者の下での勤務が中断した人の、その中断前に引き続き勤務した期間"]
[null,null,null,null,"（一時他に勤務することとなった際に、その支払者から退職手当等を受けなかった場合に限ります｡)"]
[null,null,"(3)",null,"他に勤務していた期間（その支払者の下で勤務しなかった期間に限ります。）で、今回の退職手当等の計算の基礎"]
[null,null,null,null,"となる期間に通算された期間"]
[null,null,"　また、「③」欄の内書には、上記の勤続期間のうち、特定役員退職手当等（※1）に係る勤続期間（以下「特定役員等勤続期間」とい"]
[null,null,"います。）の有無及び短期退職手当等（※2）に係る勤続期間（以下「短期勤続期間」といいます。）の有無、有の場合は、その勤続"]
[null,null,"期間及びその年数（１年未満の端数切上げ）を記載します。"]
[null,null,"　更に、特定役員等勤続期間の内書として、特定役員等勤続期間と一般退職手当等（※3）に係る勤続期間（以下「一般勤続期間」とい"]
[null,null,"います。）の重複の有無及び特定役員等勤続期間と短期勤続期間の重複の有無、有の場合は、その重複勤続期間及びその年数（１年"]
[null,null,"未満の端数切上げ）を記載します。"]
[null,null,"※1",null,"特定役員退職手当等とは、役員等としての勤続年数（以下「役員等勤続年数」といいます。）が５年以下である人が支払を受ける"]
[null,null,null,null,"退職手当等のうち、その役員等勤続年数に対応する退職手当等として支払を受けるものをいいます。"]
[null,null,null,null,"上記の役員等とは次に掲げる人をいいます。"]
[null,null,null,null,"イ",null,"法人税法第２条第15 号に規定する役員"]
[null,null,null,null,"ロ",null,"国会議員及び地方公共団体の議会の議員"]
[null,null,null,null,"ハ",null,"国家公務員及び地方公務員"]
[null,null,2,null,"短期退職手当等とは、短期勤続年数（役員等以外の者として勤務した期間により計算した勤続年数が５年以下であるものをいい、"]
[null,null,null,null,"この勤続年数については、役員等として勤務した期間がある場合、その期間を含めて計算します。以下同じです。）に対応する退"]
[null,null,null,null,"職手当等として支払を受けるものであって、特定役員退職手当等に該当しないものをいいます。"]
[null,null,3,null,"一般退職手当等とは、退職手当等のうち、特定役員退職手当等及び短期退職手当等のいずれにも該当しないものをいいます。"]
["４",null,"「④」欄には、本年中に支払を受けた他の退職手当等についての勤続期間を上記３の方法で計算して記載します。また、内書は、上"]
[null,null,"記３「③」欄の内書に倣い記載します。"]
["５",null,"「⑤」欄には､｢③」欄と「④」欄の勤続期間について、重複する部分は二重に計算しないように通算した勤続期間とその年数（１年"]
[null,null,"未満の端数切上げ）を記載します。"]
[null,null,"　また、内書の「うち 特定役員等勤続期間」並びにその内書の「うち 一般勤続期間との重複勤続期間」、「うち 短期勤続期間との"]
[null,null,"重複勤続期間」及び「うち 短期勤続期間」の各欄は、上記３「③」欄の内書に倣い記載しますが、これらの重複勤続期間には全重複"]
[null,null,"勤続期間（特定役員等勤続期間、短期勤続期間及び一般勤続期間が重複している期間をいいます。以下同じです。）を含みません。"]
[null,null,"　更に、「うち 全重複勤続期間」欄は全重複勤続期間について、「うち 短期勤続期間」の内書の「うち 一般勤続期間との重複勤続"]
[null,null,"期間」欄は短期勤続期間と一般勤続期間が重複している期間（全重複勤続期間を除きます。）について、その該当の有無、有の場合"]
[null,null,"は、その重複勤続期間及びその年数（１年未満の端数切上げ）を記載します。"]
["６",null,"「⑥」欄には、前年以前４年内（その年に確定拠出年金法に基づく老齢給付金として支給される一時金の支払を受ける場合には、19 "]
[null,null,"年内）に支払を受けた退職手当等（以下「４年内の退職手当等」といいます｡)がある場合に、その４年内の退職手当等についての勤"]
[null,null,"続期間を記載します。"]
[null,null,"　ただし、４年内の退職手当等の収入金額がその退職手当等についての退職所得控除額に満たなかったときは、その４年内の退職手"]
[null,null,"当等の収入金額に応じ、その４年内の退職手当等についての勤続期間の初日から次表の算式によって計算した数（小数点以下の端数"]
[null,null,"切捨て）に相当する年数が経過する日までの期間を記載します。"]
[]
[null,null,null,"4年内の退職手当等の収入金額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"算　　　　　　　式"]
[null,null,null,"800万円以下の場合",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その収入金額÷40万円"]
[null,null,null,"800万円を超える場合",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（その収入金額―800万円）÷70万円＋20"]
[]
["７",null,"「⑦」欄には､｢③」欄又は「⑤」欄の勤続期間のうち､｢⑥」欄の勤続期間と重複している期間を記載します。また、「㋑」欄及び"]
[null,null,"「㋺」欄には、この重複している期間のうち、「③」欄又は「⑤」欄の特定役員等勤続期間又は短期勤続期間と重複する期間の有"]
[null,null,"無、有の場合は、その重複勤続期間及びその年数（１年未満の端数切捨て）を記載します。"]
["８",null,"「⑧」欄又は「⑨」欄には､｢③」欄又は「④」欄の勤続期間のうち、その勤続期間に通算された、前の退職手当等についての勤続"]
[null,null,"期間（上記３の(1)又は(3)の期間（(3)の期間については、その「他」の勤務先から前に退職手当等の支払を受けている場合に限"]
[null,null,"ります｡)）とその年数（１年未満の端数切捨て）を記載します。また、内書には、その勤続期間のうち、特定役員等勤続期間又は"]
[null,null,"短期勤続期間の有無、有の場合は、その特定役員等勤続期間又はその短期勤続期間及びその年数（１年未満の端数切捨て）を記載"]
[null,null,"します。"]
["９",null,"「⑩」欄には､「③」欄又は｢⑤」欄の勤続期間のうち､｢⑧」欄又は「⑨」欄の勤続期間だけからなる部分の期間とその年数（１年"]
[null,null,"未満の端数切捨て）を記載します。また、「㋩」欄及び「㋥」欄には、その勤続期間のうち、特定役員等勤続期間又は短期勤続期"]
[null,null,"間の有無、有の場合は、その特定役員等勤続期間又はその短期勤続期間及びその年数（１年未満の端数切捨て）を記載します。"]
[10,null,"「⑪」欄には､｢⑦」欄と「⑩」欄の勤続期間について、重複する部分は二重に計算しないように通算した勤続期間とその年数（１"]
[null,null,"年未満の端数切捨て）を記載します。また「㋭」欄及び「㋬」欄には、「㋑」欄と「㋩」欄及び「㋺」欄と「㋥」欄の勤続期間に"]
[null,null,"ついて、重複する部分は二重に計算しないように通算した勤続期間とその年数（１年未満の端数切捨て）を記載します。"]

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