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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,"　　　　年　　月　　日"]
[null,"子育てのための施設等利用給付認定・変更申請書(法第30条の4第2号・第3号) "]
["　四日市市長"]
[]
[]
[null,"　【申請にあたって同意していただく事項】"]
[null,"1.","子ども・子育て支援法第３０条の３において準用する同法第１６条の規定に基づき、施設等利用給付認定の審査及び申請者や同居親族の市町村民税課税状況の確認に当たって、官公署に対し必要な文書の閲覧又は資料の提供を求めることがあります（マイナンバー制度による情報連携を含む。)。"]
[]
[null,"2.","申請書等に記載した内容は、施設等利用給付認定や施設等利用費の支給に関する情報として必要と認められる場合に、施設・事業者に提供することがあります。"]
[]
[null,"3.","子ども・子育て支援法第３０条の１１の規定に基づき、施設等利用費は、認定を受けた保護者に代わり、特定子ども・子育て支援提供者に支給される場合があります。"]
[]
[null,"4.","新年度４月利用開始の場合は、認定事務が集中し審査等に日時を要するため、申請日に関わらず、子ども・子育て支援法第３０条の５第５項の規定に基づき、最長で利用開始の前日まで審査結果のお知らせを延期する場合があります。"]
[]
[null,"5.","申請内容が事実と相違した場合は、施設等利用給付認定を取り消すことがあります。"]
[null,"6.","認定希望日現在で、子ども・子育て支援法第７条第１０項第４号ハの政令で定める施設（企業主導型保育事業）の利用がある場合は、本認定の申請はできません。"]
[]
[]
[null,"　以上のことに同意し、保護者の就労、疾病その他の理由により、幼稚園・認定こども園・特別支援学校(預かり保育事業も利用する(※1))、認可外保育施設、一時預かり事業、病児保育事業、子育て援助活動支援事業の施設等利用給付認定を希望するので、子ども・子育て支援法第３０条の５第1項の規定に基づき、次のとおり施設等利用給付に係る認定を申請します。"]
[null,"※1.","預かり保育事業とは、当該幼稚園等が実施する預かり保育事業が、①平日、教育時間を含み提供時間数が８時間未満または②年間開所日数200日未満のいずれかの要件に該当する場合に利用可能な認可外保育施設を含みます。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"認定希望日（施設利用開始日）",null,null,null,null,null,null,null,null,"　　　　年　　月　　日"]
[null,"保護者",null,"フリガナ",null,null,null,null,null,null,null,null,null,"申請\n子ども\nとの続柄",null,null,null,"居住地",null,"〒",null,null,"－"]
[null,null,null,"氏名",null,null,"※　自署の場合は印は不要です。",null,null,null,null,null,"印"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"現住所が市外の場合\n市内転入後の住所",null,null,null,"〒　"]
[]
[null,null,null,"日中の連絡先（電話番号）＊確実に連絡の取れる順に記入して下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,"　　　　年　　月　　日"]
[null,null,null,"①",null,null,null,null,"父携帯　・　母携帯\n父勤務先　・　母勤務先\n自宅・その他（　　　）",null,null,null,"②",null,null,null,null,"父携帯　・　母携帯\n父勤務先　・　母勤務先\n自宅・その他（　　　）",null,null,null,"個人番号\n(マイナンバー)"]
[]
[null,null,null,"家庭状況",null,null,null,null,"□  ひとり親家庭",null,null,null,null,null,null,null,"□   左記以外"]
[null,"申請\n子ども",null,"フリガナ",null,null,null,null,null,null,null,null,"現住所\n申請者と異なる\n場合のみ記載",null,null,"〒",null,null,"－",null,null,null,null,null,"個人番号(マイナンバー)"]
[null,null,null,"氏名"]
[null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,null,"年",null,"月",null,"日"]
[null,"認定種別",null,"□","申請子どもは、認定希望日時点で満３歳に達する日以後の最初の３月３１日を経過している(第2号)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左記で第3号に該当し、市民税非課税世帯に該当する場合は、\n下の□にレ点を付けて下さい。"]
[]
[null,null,null,"□","申請子どもは、認定希望日時点で満３歳に達する日以後の最初の３月３１日までの間にある(第3号)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□","市民税所得割非課税に該当"]
[null,"保育を必要とする理由",null,"該当する□にレ点を付けて下さい。"]
[null,null,null,"（子から見た続柄）　　　　　　",null,null,null,null,"□","就労","□","妊娠\n出産","□","疾病\n障害等",null,"□","介護\n看護","□","災害\n復旧","□","求職\n活動等",null,"□","就学","□","その他（",null,null,null,"）"]
[null,null,null,"父・母・その他（　　　　　　）"]
[null,null,null,"（子から見た続柄）　　　　　　",null,null,null,null,"□","就労","□","妊娠\n出産","□","疾病\n障害等",null,"□","介護\n看護","□","災害\n復旧","□","求職\n活動等",null,"□","就学","□","その他（",null,null,null,"）"]
[null,null,null,"父・母・その他（　　　　　　）"]
[]
[null,"上記「認定種別」が(第3号)に該当する場合に記入して下さい。"]
[null,"認定希望日の\n前年1月1日現在の住所\n※2",null,null,null,null,"(母親)",null,null,null,null,null,null,null,null,null,null,null,"(父親)"]
[null,null,null,null,null,null,null,null,"□　現住所と同じ",null,null,null,null,null,null,null,null,null,null,null,"□　現住所と同じ"]
[null,"認定希望日の\n前々年1月1日現在の住所\n※3",null,null,null,null,"(母親)",null,null,null,null,null,null,null,null,null,null,null,"(父親)"]
[null,null,null,null,null,null,null,null,"□　現住所と同じ",null,null,null,null,null,null,null,null,null,null,null,"□　現住所と同じ"]
[]
[null,"同居者を全員記入して下さい。（※生計を一にしている別居の家族や世帯分離している同居の祖父母等も記入してください。）"]
[null,"その他の家族（申請子ども以外 ）",null,null,"フリガナ",null,null,null,null,null,null,null,"申請子ども\nとの続柄",null,"生年月日",null,null,null,null,null,null,null,"就労・通学・通園先\n又は単身赴任先",null,null,null,null,null,"要介護認定又は障害者手帳"]
[null,null,null,null,"氏名"]
[null,null,null,1,null,null,null,null,null,null,null,null,null,null,"大正　昭和\n平成　令和           年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"□有"]
[]
[null,null,null,2,null,null,null,null,null,null,null,null,null,null,"大正　昭和\n平成　令和           年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"□有"]
[]
[null,null,null,3,null,null,null,null,null,null,null,null,null,null,"大正　昭和\n平成　令和           年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"□有"]
[]
[null,null,null,4,null,null,null,null,null,null,null,null,null,null,"大正　昭和\n平成　令和           年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"□有"]
[]
[null,null,null,5,null,null,null,null,null,null,null,null,null,null,"大正　昭和\n平成　令和           年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"□有"]
[]
[null,null,null,6,null,null,null,null,null,null,null,null,null,null,"大正　昭和\n平成　令和           年　　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"□有"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜必ず裏面も記入して下さい＞"]
[]
[null,"幼稚園・認定こども園・特別支援学校幼稚部を利用する(予定含む)方は記入して下さい。"]
[null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,"所在地",null,null,"〒",null,"－",null,null,"℡",null,null,"(　　　)"]
[null,"施設名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"利用開始予定日",null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[]
[null,"認可外保育施設、一時預かり事業、病児保育事業、子育て援助活動支援事業を利用する(予定含む)方は記入して下さい。"]
[null,"フリガナ",null,null,null,null,null,null,null,null,"利用するサービス\nの種類",null,null,null,null,null,"所在地",null,null,null,null,null,null,null,null,"利用開始予定日"]
[null,"施設名"]
[null,null,null,null,null,null,null,null,null,null,"認可外  ・  一時預かり \n病児保育・子育て援助活動",null,null,null,null,null,"〒　　　－",null,null,null,null,null,null,null,null,"　　　　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,"TEL:　　　－　　　－　　　"]
[null,null,null,null,null,null,null,null,null,null,"認可外  ・  一時預かり \n病児保育・子育て援助活動",null,null,null,null,null,"〒　　　－",null,null,null,null,null,null,null,null,"　　　　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,"TEL:　　　－　　　－　　　"]
[null,null,null,null,null,null,null,null,null,null,"認可外  ・  一時預かり \n病児保育・子育て援助活動",null,null,null,null,null,"〒　　　－",null,null,null,null,null,null,null,null,"　　　　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,"TEL:　　　－　　　－　　　"]
[null,null,null,null,null,null,null,null,null,null,"認可外  ・  一時預かり \n病児保育・子育て援助活動",null,null,null,null,null,"〒　　　－",null,null,null,null,null,null,null,null,"　　　　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,"TEL:　　　－　　　－　　　"]
[]
[null,"保育を必要とする理由に応じて記入して下さい。"]
[null,null,null,null,"母親の状況",null,null,null,null,null,null,null,null,null,null,null,null,"父親の状況"]
[null,"就労","就労\n種別",null,"□","居宅外労働",null,null,null,null,null,null,null,null,null,null,null,"□","居宅外労働"]
[null,null,null,null,"□","自営　⇒",null,null,"□","自宅",null,null,"□","中心者",null,null,null,"□","自営　⇒",null,null,"□","自宅",null,null,"□","中心者"]
[null,null,null,null,null,null,null,null,"□","自宅以外",null,null,"□","協力者",null,null,null,null,null,null,null,"□","自宅以外",null,null,"□","協力者"]
[null,null,null,null,"□","内職",null,null,"□","その他：",null,"（",null,null,null,null,"）","□","内職",null,null,"□","その他：",null,"（",null,null,null,null,"）"]
[null,null,"通勤手段\n・時間",null,"通勤手段",null,"徒歩・自転車・バス・自動車・電車・その他（　　　）",null,null,null,null,null,null,null,null,null,null,"通勤手段",null,"徒歩・自転車・バス・自動車・電車・その他（　　　）"]
[null,null,null,null,null,null,"※複数手段がある場合は全てに○をつけて下さい。",null,null,null,null,null,null,null,null,null,null,null,null,"※複数手段がある場合は全てに○をつけて下さい。"]
[null,null,null,null,"通勤時間",null,"約",null,"分","（往復時間を記入して下さい。）",null,null,null,null,null,null,null,"通勤時間",null,"約",null,"分","（往復時間を記入して下さい。）"]
[null,null,"前年１月１日以降の転職",null,"□","無",null,null,null,null,null,null,null,null,null,null,null,"□","無"]
[null,null,null,null,"□","有　⇒",null,"就労先名：",null,null,null,null,null,null,null,null,null,"□","有　⇒",null,"就労先名："]
[null,null,null,null,null,null,null,"就労期間：",null,null,null,null,null,"から",null,null,null,null,null,null,"就労期間：",null,null,null,null,null,"から"]
[null,null,null,null,null,null,null,"就労先名：",null,null,null,null,null,null,null,null,null,null,null,null,"就労先名："]
[null,null,null,null,null,null,null,"就労期間：",null,null,null,null,null,"から",null,null,null,null,null,null,"就労期間：",null,null,null,null,null,"から"]
[null,"妊娠・出産\n（申請時点）",null,null,"□","無"]
[null,null,null,null,"□","有　⇒",null,"（予定日）",null,null,null,null,"年",null,"月",null,"日"]
[null,"疾病・障害\n等",null,null,"（疾病・障害名）",null,null,null,null,null,null,null,"（手帳交付）",null,null,null,null,"（疾病・障害名）",null,null,null,null,null,null,null,"（手帳交付）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"□","有","□","無",null,null,null,null,null,null,null,null,null,"□","有","□","無"]
[null,"介護・看護","被介護者名",null,null,null,null,null,null,null,"（申請子どもとの続柄：　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"（申請子どもとの続柄：　　　　）"]
[null,null,"傷病・障害名"]
[null,null,"受診等\nの状況",null,"□入院中　　通院(月・週　　　　回）",null,null,null,null,null,null,null,null,null,null,null,null,"□入院中　　通院(月・週　　　　回）"]
[null,null,null,null,"□通所・通学（週　　　　回）",null,null,null,null,null,null,null,null,null,null,null,null,"□通所・通学（週　　　　回）"]
[null,null,null,null,"　施設名（　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"　施設名（　　　　　　　　　　　　　　　　　）"]
[null,"災害復旧",null,null,"災害の状況：",null,null,null,null,null,null,null,null,null,null,null,null,"災害の状況："]
[]
[null,"求職活動等",null,null,"活動の内容：",null,null,null,null,null,null,null,null,null,null,null,null,"活動の内容："]
[]
[null,"就学","通学手段\n・時間",null,"通学手段",null,"徒歩・自転車・バス・自動車・電車・その他（　　　　　）",null,null,null,null,null,null,null,null,null,null,"通学手段",null,"徒歩・自転車・バス・自動車・電車・その他（　　　　）"]
[null,null,null,null,null,null,"※複数手段がある場合は全てに○をつけて下さい。",null,null,null,null,null,null,null,null,null,null,null,null,"※複数手段がある場合は全てに○をつけて下さい。"]
[null,null,null,null,"通学時間",null,"約",null,"分","（往復時間を記入して下さい。）",null,null,null,null,null,null,null,"通学時間",null,"約",null,"分","（往復時間を記入して下さい。）"]
[null,null,"就学の\n目的",null,"　□　卒業後就労するため　□その他（ 　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"　□　卒業後就労するため　□その他（ 　　　　）"]
[]
[null,null,"期間",null,null,null,null,"年",null,"月",null,"日まで",null,null,null,null,null,null,null,null,"年",null,"月",null,"日まで"]
[]
[null,null,"卒業後\nの予定",null,"（就労日数・時間）",null,null,null,null,"□","週",null,"日、１日",null,null,"時間就労",null,"（就労日数・時間）",null,null,null,null,"□","週",null,"日、１日",null,null,"時間就労"]
[null,null,null,null,null,null,null,null,null,"□","月",null,null,null,null,null,null,null,null,null,null,null,"□","月"]
[null,"その他",null,null,"保育を行うことが困難と認められる内容",null,null,null,null,null,null,null,null,null,null,null,null,"保育を行うことが困難と認められる内容"]
[]
[]
[]
[null,"添付書類　（以下の中から該当する書類を添付して下さい）"]
[null,1,"居宅外で就労されている方（予定を含む）",null,null,null,null,null,null,null,null,null,null,null,null,"就労証明書(就労内定の場合はその証明を受けて下さい)"]
[null,null,"自営(自宅外自営、親族経営等の自営を含む)の場合",null,null,null,null,null,null,null,null,null,null,null,null,"就労証明書、自営の証明書類の写し(確定申告書、営業許可証、 開業届等)"]
[null,2,"出産前後の方（出産前８週間・後８週間に限る）",null,null,null,null,null,null,null,null,null,null,null,null,"母子健康手帳の写し(氏名と出産予定日が記載されているページ)"]
[null,3,"保護者が学校に在学中の方",null,null,null,null,null,null,null,null,null,null,null,null,"在学証明書(入学予定の場合は合格通知等)"]
[null,4,"保護者が病気の方",null,null,null,null,null,null,null,null,null,null,null,null,"診断書"]
[null,5,"保護者が障害をお持ちの方",null,null,null,null,null,null,null,null,null,null,null,null,"障害による手帳等の交付を受けている方…身体障害者手帳、療育手帳、精神障害者保健福祉手帳の写し\n交付を受けていない方…診断書"]
[null,6,"保護者が介護している方",null,null,null,null,null,null,null,null,null,null,null,null,"申立書及び介護が必要であることがわかる書類(診断書、介護保険証の写し等)"]
[null,7,"保護者が求職中の方",null,null,null,null,null,null,null,null,null,null,null,null,"約束書"]
[null,8,"認可外保育施設の利用を希望される方",null,null,null,null,null,null,null,null,null,null,null,null,"保育所等利用申し込み等の不実施に係る理由書"]