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{"sheet":"申請書（表）","index":0,"n_rows":45,"n_cols":39,"rows_kept":45,"cut":false,"hidden":false,"merged":[[15,0,15,38],[23,1,28,6],[23,7,23,21],[23,22,23,36],[24,7,24,21],[24,22,24,36],[26,7,26,20],[25,7,25,20],[25,21,25,36],[26,35,26,36],[17,15,17,22],[26,31,26,32],[26,33,26,34],[27,7,27,15],[28,7,28,15],[27,16,27,36],[17,1,17,9],[40,28,40,36],[22,2,22,22],[20,2,20,22],[20,23,20,27],[21,23,21,27],[22,23,22,27],[28,16,28,36],[26,21,26,22],[26,23,26,24],[26,25,26,26],[26,27,26,28],[26,29,26,30],[2,0,2,38],[4,35,4,36],[4,32,4,33],[4,29,4,30],[44,28,44,36],[43,20,44,22],[43,24,43,27],[44,24,44,27],[41,20,41,26],[42,20,42,26],[41,28,41,36],[42,28,42,36],[43,28,43,36],[39,20,40,27],[39,29,39,32],[6,0,6,6]]}
["別記第１号様式（第４条）"]
[]
["令和８年度茂原市介護サービス事業所・施設等物価高騰対策支援金申請書兼請求書"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　令和",8,null,"年",null,null,"月",null,null,"日"]
[]
["（宛先）茂原市長"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"法人所在地"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"法人名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"代表者職氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"印"]
[]
["　令和８年度茂原市介護サービス事業所・施設等物価高騰対策支援金交付要綱第４条の規定により、"]
["関係書類を添えて下記のとおり申請します。"]
[]
["記"]
[]
["１","申請額（請求額）　",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"'請求額内訳書（裏）'!E26","v":0},null,null,null,null,null,null,null,"円"]
[]
[]
[]
["２","振込先（申請者名義のもの）"]
[]
[null,"振込先口座",null,null,null,null,null,"金融機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"本店・支店名"]
[]
[null,null,null,null,null,null,null,"預金種別",null,null,null,null,null,null,null,null,null,null,null,null,null,"口座番号（右詰め）"]
[null,null,null,null,null,null,null,"普通　・　当座"]
[null,null,null,null,null,null,null,"フリガナ"]
[null,null,null,null,null,null,null,"口座名義人"]
[]
["３","添付書類"]
[]
[null,"（１）振込先金融機関の通帳等の写し（口座番号、口座名義人が記載されているページのみ）"]
[]
[null,"（２）その他市長が必要と認める書類"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【申請内容に関する連絡先】"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 申請法人住所",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," 部署名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 担当者氏名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 連絡先",null,null,null,"電話番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"e-mail"]

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["４　申請額（請求額）内訳"]
["区分","事業種別","事業所数","支援金額","申請額"]
[null,null,null,null,"（請求額）"]
["訪問系","居宅介護支援",null,30000,{"$f":"C4*$D$4","v":0}]
[null,"訪問介護",null,50000,{"$f":"D5*SUM(C5:C7)","v":0}]
[null,"訪問入浴介護"]
[null,"特定福祉用具販売・福祉用具貸与"]
["通所系","通所介護",null,100000,{"$f":"D8*SUM(C8:C11)","v":0}]
[null,"地域密着型通所介護"]
[null,"通所リハビリテーション"]
[null,"認知症対応型通所介護"]
["入所系","小規模多機能型居宅介護",null,150000,{"$f":"D12*SUM(C12:C17)","v":0}]
[null,"複合型サービス"]
[null,"認知症対応型共同生活介護"]
[null,"特定施設入居者生活介護"]
[null,"短期入所生活介護（単独型）"]
[null,"養護老人ホーム"]
[null,"介護老人福祉施設",null,"定員総数30人未満",{"$f":"(D19*C18)+(D21*C20)","v":0}]
[null,null,null,150000]
[null,null,null,"定員総数30人以上"]
[null,null,null,250000]
[null,"介護老人保健施設",null,250000,{"$f":"$D$22*C22","v":0}]
[null,"軽費老人ホーム",null,50000,{"$f":"D23*SUM(C23:C25)","v":0}]
[null,"有料老人ホーム"]
[null,"サービス付き高齢者向け住宅"]
["合計額",null,null,null,{"$f":"SUM(E4:E25)","v":0}]
["※表面「１申請額（請求額）」に転記してください。"]

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[null,null,null,null,null,null,null,"※本シートは絶対に編集しないこと。"]
["施設区分"]
["陽性者(濃厚接触者)発生施設","通所系･施設系で1日以上勤務又は訪問系で陽性者等に1日以上対応","訪問系で陽性者等への対応はないが対象期間に10日以上勤務","対象期間の勤務が９日以下"]
["その他の施設","対象期間に10日以上勤務","対象期間の勤務が9日以下"]
[]
[]
["慰労金単価"]
[{"$f":"A3&B3","v":"陽性者(濃厚接触者)発生施設通所系･施設系で1日以上勤務又は訪問系で陽性者等に1日以上対応"},20]
[{"$f":"A3&C3","v":"陽性者(濃厚接触者)発生施設訪問系で陽性者等への対応はないが対象期間に10日以上勤務"},5]
[{"$f":"A3&D3","v":"陽性者(濃厚接触者)発生施設対象期間の勤務が９日以下"},0]
[{"$f":"A4&B4","v":"その他の施設対象期間に10日以上勤務"},5]
[{"$f":"A4&C4","v":"その他の施設対象期間の勤務が9日以下"},0]
[]
[]
[]
[]
["なし"]
["あり"]
[]
[]
["北海道"]
["青森県"]
["岩手県"]
["宮城県"]
["秋田県"]
["山形県"]
["福島県"]
["茨城県"]
["栃木県"]
["群馬県"]
["埼玉県"]
["千葉県"]
["東京都"]
["神奈川県"]
["新潟県"]
["富山県"]
["石川県"]
["福井県"]
["山梨県"]
["長野県"]
["岐阜県"]
["静岡県"]
["愛知県"]
["三重県"]
["滋賀県"]
["京都府"]
["大阪府"]
["兵庫県"]
["奈良県"]
["和歌山県"]
["鳥取県"]
["島根県"]
["岡山県"]
["広島県"]
["山口県"]
["徳島県"]
["香川県"]
["愛媛県"]
["高知県"]
["福岡県"]
["佐賀県"]
["長崎県"]
["熊本県"]
["大分県"]
["宮崎県"]
["鹿児島県"]
["沖縄県"]