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[null,null,null,null,null,null,null,null,"2024-08-28"]
["事業所雇用保険ご担当者様"]
[]
[]
[null,null,null,null,null,null,null,"三島公共職業安定所"]
[null,null,null,null,null,null,null,"雇用保険課"]
[]
[]
["離職票作成シミュレーションツール（sbs-r）について"]
[]
["１　使用方法"]
["　　使用法は、別添の「ツール使用マニュアル」をご覧ください。"]
[]
["２　注意点"]
["　（１）適正な申請を阻害する可能性があるため、当ファイルの改造は行わないでください。"]
["　（２）当ファイルで作成したものを申請書として提出することはできません。"]
[]
["　"]

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[]
[null,null,null,"離職日","2024-08-28",null,null,null,null,"傷病等により、就労ができずかつ、賃金の支払いがなかった期間"]
[null,null,null,"資格取得日","2014-04-01",null,null,null,null,"2021-05-12","～","2023-03-31"]
[null,null,null,"賃金締切日",25,null,null,null,null,"※実行により色がついた箇所は省略が可能です。"]
[null,null,null,"賃金形態","日給月給（その他）",null,null,null,null,"日数",{"$f":"L3-J3+1","v":689}]
[null,null,null,"基礎日数",21,"←日給月給制で基礎日数が定数の場合のみ入力"]
[null,null,"離職日の翌日",null,"2024-08-29","⑨欄","⑩欄",null,null,"⑪欄","⑫欄",null,null,"⑬欄"]
[null,null,"⑧欄",null,null,null,null,null,null,null,"A欄（月給的賃金）","B欄（変動的賃金）","計",null,null,"出産日","2023-03-17"]
[null,1,null,"～",null,null,null,"～",null,null,null,null,{"$f":"IFERROR(K9+L9,\"\")","v":0},null,null,"出産予定日","2022-01-01"]
[null,2,null,"～",null,null,null,"～",null,null,null,null,{"$f":"IFERROR(K10+L10,\"\")","v":0},null,null,"産前開始日",{"$f":"DATE(YEAR(Q9),MONTH(Q9),DAY(Q9)-41)","v":"2021-11-21"}]
[null,3,null,"～",null,null,null,"～",null,null,null,null,0,null,null,"産後終了日",{"$f":"DATE(YEAR(Q8),MONTH(Q8),DAY(Q8)+56)","v":"2023-05-12"}]
[null,4,null,"～",null,null,null,"～",null,null,null,null,0,null,null,"※多胎妊娠の場合は産前９８日です。"]
[null,5,null,"～",null,null,null,"～",null,null,null,null,0]
[null,6,null,"～",null,null,null,"～",null,null,null,null,0,null,null,"⑧～⑨の抹消開始",12]
[null,7,null,"～",null,null,null,"～",null,null,null,null,0,null,null,"⑩～⑬の抹消開始",25]
[null,8,null,"～",null,null,null,"～",null,null,null,null,0]
[null,9,null,"～",null,null,null,"～",null,null,null,null,0]
[null,10,null,"～",null,null,null,"～",null,null,null,null,0]
[null,11,null,"～",null,null,null,"～",null,null,null,null,0]
[null,12,null,"～",null,null,null,"～",null,null,null,null,0]
[null,13,null,"～",null,null,null,"～",null,null,null,null,0]
[null,14,null,"～",null,null,null,"～",null,null,null,null,0]
[null,15,null,"～",null,null,null,"～",null,null,null,null,0]
[null,16,null,"～",null,null,null,"～",null,null,null,null,0]
[null,17,null,"～",null,null,null,"～",null,null,null,null,0]
[null,18,null,"～",null,null,null,"～",null,null,null,null,0]
[null,19,null,"～",null,null,null,"～",null,null,null,null,0]
[null,20,null,"～",null,null,null,"～",null,null,null,null,0]
[null,21,null,"～",null,null,null,"～",null,null,null,null,0]
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[null,28,null,"～",null,null,null,"～",null,null,null,null,0]
[null,29,null,"～",null,null,null,"～",null,null,null,null,0]
[null,30,null,"～",null,null,null,"～",null,null,null,null,0]
[null,31,null,"～",null,null,null,"～",null,null,null,null,0]
[null,32,null,"～",null,null,null,"～",null,null,null,null,0]
[null,33,null,"～",null,null,null,"～",null,null,null,null,0]
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[null,38,null,"～",null,null,null,"～",null,null,null,null,0]
[null,39,null,"～",null,null,null,"～",null,null,null,null,0]
[null,40,null,"～",null,null,null,"～",null,null,null,null,0]
[null,41,null,"～",null,null,null,"～",null,null,null,null,0]
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[null,43,null,"～",null,null,null,"～",null,null,null,null,0]
[null,44,null,"～",null,null,null,"～",null,null,null,null,0]
[null,45,null,"～",null,null,null,"～",null,null,null,null,0]
[null,46,null,"～",null,null,null,"～",null,null,null,null,0]
[null,47,null,"～",null,null,null,"～",null,null,null,null,0]
[null,48,null,"～",null,null,null,"～",null,null,null,null,0]
[null,49,null,"～",null,null,null,"～",null,null,null,null,0]
[null,50,null,"～",null,null,null,"～",null,null,null,null,0]
[null,51,null,"～",null,null,null,"～",null,null,null,null,0]
[null,52,null,"～",null,null,null,"～",null,null,null,null,0]
[]
[null,null,"離職日から２年間を満たす日"]
[null,null,"離職日から４年間を満たす日"]

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[]
[]
[null,null,null,null,"雇用保険被保険者離職票ー２"]
[null,"様式第６号（２）（第７条関係）"]
[null,"①\n被保険者番号",null,null,null,"　③","フリガナ",null,null,null,null,"　④\n　   離　職\n　   年月日"]
[null,"②\n事業所番号",null,null,null,"　離職者氏名"]
[null,"⑤",null,null,null,null,null,null," ⑥\n\n 離   職   者  の\n 住所又は居所","〒"]
[null,"               名称"]
[null,"事業所 所在地"]
[null,"         電話番号",null,null,null,null,null,null,null,"電話番号",null,null,null,"－"]
[null,null,null,null,null,null,null,null,null,"※",null,null,"付で交付した離職票ー１"]
[null,"住所",null,null,null,null,null,null,null,null,"（交付番号",null,"）に係る賃金支払状況である。"]
[null,"事業主"]
[null,"氏名",null,null,null,null,null,null,null,null,null,"三島公共職業安定所　印"]
[null,"離 職 の 日 以 前 の 賃 金 支 払 状 況 等"]
[null,"⑧ 被保険者期間算定対象期間",null,null,null,"⑨\n⑧の期間\nにおける\n賃金支払\n基礎日数","⑩\n\n             賃 金 支 払 対 象 期 間",null,null,"⑪\n  ⑩ の\n  基 礎\n  日 数","⑫\n　　　　　賃　　　　金　　　　　額",null,null,"⑬\n　 備　考"]
[null,"（A） 一般被保険者等",null,null,"(B) 短期\n雇用特例\n被保険者"]
[null,"離職日の翌日",null,null,null,null,null,null,null,null,"（A)","（B)","計"]
[null,"月　日","～","　　離職日","　月","　 日","月　日","～","　　離職日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"月　日","～","月　日","　月","　 日","月　日","～","月　日"," 　日"]
[null,"　⑭\n　賃  金  に\n　関  す  る\n　特記事項",null,null,null,null,null,null,null,null,"　□運転免許証　　　　　□個人番号カード\n　□旅券　　　　　　　　□住民票記載事項証明書\n　□国民健康保険被保険者証（健康保険被保険者証）\n　□その他（　　　　　　　　　　　　　　　　　　　　　　　）　"]
[]
[]
[]
[null,"　※公共職業安定所記載欄"]
[null,null,"　⑮欄の記載",null,"□有・□無"]
[null,null,"　⑯欄の記載",null,"□有・□無"]
[null,null,"□資・□聴"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"注意"]
[null,"１．基本手当は受給資格者が、高年齢求職者給付金は高年齢受給資格者が、特例一時金は特例受給資格者が、それぞれ労働の意思及び能力を有するにもかかわらず職業に就くことができない"]
[null,"　ときに支給されるものであること。"]
[null,"２．基本手当、高年齢求職者給付金又は特例一時金の支給を受けようとするときは、住所又は居所を管轄する公共職業安定所又は地方運輸局に出頭し、求職の申し込みをした上、この離職"]
[null,"　票ー２及び離職票ー１（別紙）を提出すること。"]
[null,"３．基本手当、高年齢求職者給付金又は特例一時金の支給を受けないときでも、後日必要な場合があるから、少なくとも4年間は大切に保存すること。"]
[null,"４．この離職票ー2を減失し、又は損傷したときは、交付を受けた公共職業安定所に申し出ること。"]
[null,"※基本手当、高年齢求職者給付金又は特例一時金の受給手続を取られる方は、裏面のⅡ「支給を受けるための手続等」をご覧ください。"]
[]
[null,"⑦離職理由欄・・・離職者の方は、主たる離職理由が該当する理由を１つ選択し、左の離職者記入欄の□の中に〇印を記入の上、下の具体的事情記載欄に具体的事情を記載してください。"]
[null," 【離職理由は所定給付日数・給付制限の有無に影響を与える場合があり、適正に記載してください。】　　"]
[null,"事業主\n記入欄","離職者\n記入欄","離　　　　職　　　　理　　　　由",null,null,null,null,null,null,null,null,null,"※離職区分"]
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[]
[null,null,null,null,"雇 用 保 険 被 保 険 者 離 職 票 ー ２",null,null,null,null,null,null,null,"続紙"]
[null,"様式第６号（２）（第７条関係）"]
[null,"①\n被保険者番号",null,null,null,"　③","フリガナ",null,null,null,null,"　④\n　   離　職\n　   年月日",{"$f":"本紙!M10","v":"00:00:00"}]
[null,"②\n事業所番号",null,null,null,"　離職者氏名"]
[null,"⑤",null,null,null,null,null,null," ⑥\n\n 離   職   者  の\n 住所又は居所",{"$f":"本紙!J12","v":"〒"}]
[null,"               名称"]
[null,"事業所 所在地"]
[null,"         電話番号",null,null,null,null,null,null,null,"電話番号",null,null,null,"－"]
[null,null,null,null,null,null,null,null,null,"※",null,null,"で交付した離職票ー１"]
[null,"住所",null,null,null,null,null,null,null,null,"（交付番号",null,"）に係る賃金支払状況である。"]
[null,"事業主"]
[null,"氏名",null,null,null,null,null,null,null,null,null,"三島公共職業安定所　印"]
[null,"離 職 の 日 以 前 の 賃 金 支 払 状 況 等"]
[null,"⑧ 被保険者期間算定対象期間",null,null,null,"⑨\n⑧の期間\nにおける\n賃金支払\n基礎日数","⑩\n\n             賃 金 支 払 対 象 期 間",null,null,"⑪\n  ⑩ の\n  基 礎\n  日 数","⑫\n　　　　　賃　　　　金　　　　　額",null,null,"⑬\n　 備　考"]
[null,"（A） 一般被保険者等",null,null,"(B) 短期\n雇用特例\n被保険者"]
[null,"離職日の翌日",null,null,null,null,null,null,null,null,"（A)","（B)","計"]
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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,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,"　⑭\n　賃  金  に\n　関  す  る\n　特記事項",null,null,null,null,null,null,null,null,"　□運転免許証　　　　　□個人番号カード\n　□旅券　　　　　　　　□住民票記載事項証明書\n　□国民健康保険被保険者証（健康保険被保険者証）\n　□その他（　　　　　　　　　　　　　　　　　　　　　　　）　"]
[]
[]
[]
[null,"　※公共職業安定所記載欄"]
[null,null,"　⑮欄の記載",null,"□有・□無"]
[null,null,"　⑯欄の記載",null,"□有・□無"]
[null,null,"□資・□聴"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"注意"]
[null,"１．基本手当は受給資格者が、高年齢求職者給付金は高年齢受給資格者が、特例一時金は特例受給資格者が、それぞれ労働の意思及び能力を有するにもかかわらず職業に就くことができない"]
[null,"　ときに支給されるものであること。"]
[null,"２．基本手当、高年齢求職者給付金又は特例一時金の支給を受けようとするときは、住所又は居所を管轄する公共職業安定所又は地方運輸局に出頭し、求職の申し込みをした上、この離職"]
[null,"　票ー２及び離職票ー１（別紙）を提出すること。"]
[null,"３．基本手当、高年齢求職者給付金又は特例一時金の支給を受けないときでも、後日必要な場合があるから、少なくとも4年間は大切に保存すること。"]
[null,"４．この離職票ー2を減失し、又は損傷したときは、交付を受けた公共職業安定所に申し出ること。"]
[null,"※基本手当、高年齢求職者給付金又は特例一時金の受給手続を取られる方は、裏面のⅡ「支給を受けるための手続等」をご覧ください。"]
[]
[null,"⑦離職理由欄・・・離職者の方は、主たる離職理由が該当する理由を１つ選択し、左の離職者記入欄の□の中に〇印を記入の上、下の具体的事情記載欄に具体的事情を記載してください。"]
[null," 【離職理由は所定給付日数・給付制限の有無に影響を与える場合があり、適正に記載してください。】　　"]
[null,"事業主\n記入欄","離職者\n記入欄","離　　　　職　　　　理　　　　由",null,null,null,null,null,null,null,null,null,"※離職区分"]
[]
[null,"□"]
[null,"□",null,null,null,null,null,null,null,null,null,null,null,null,null,null,1101]
[]
[null,"□"]
[]
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[null,"□"]
[]
[]
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[null,"□"]
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[null,"□"]
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[]
[]
[null,null,null,null,"雇 用 保 険 被 保 険 者 離 職 票 ー ２",null,null,null,null,null,null,null,"続紙"]
[null,"様式第６号（２）（第７条関係）"]
[null,"①\n被保険者番号",null,null,null,"　③","フリガナ",null,null,null,null,"　④\n　   離　職\n　   年月日",{"$f":"本紙!M10","v":"00:00:00"}]
[null,"②\n事業所番号",null,null,null,"　離職者氏名"]
[null,"⑤",null,null,null,null,null,null," ⑥\n\n 離   職   者  の\n 住所又は居所",{"$f":"本紙!J12","v":"〒"}]
[null,"               名称"]
[null,"事業所 所在地"]
[null,"         電話番号",null,null,null,null,null,null,null,"電話番号",null,null,null,"－"]
[null,null,null,null,null,null,null,null,null,"※",null,null,"で交付した離職票ー１"]
[null,"住所",null,null,null,null,null,null,null,null,"（交付番号",null,"）に係る賃金支払状況である。"]
[null,"事業主"]
[null,"氏名",null,null,null,null,null,null,null,null,null,"三島公共職業安定所　印"]
[null,"離 職 の 日 以 前 の 賃 金 支 払 状 況 等"]
[null,"⑧ 被保険者期間算定対象期間",null,null,null,"⑨\n⑧の期間\nにおける\n賃金支払\n基礎日数","⑩\n\n             賃 金 支 払 対 象 期 間",null,null,"⑪\n  ⑩ の\n  基 礎\n  日 数","⑫\n　　　　　賃　　　　金　　　　　額",null,null,"⑬\n　 備　考"]
[null,"（A） 一般被保険者等",null,null,"(B) 短期\n雇用特例\n被保険者"]
[null,"離職日の翌日",null,null,null,null,null,null,null,null,"（A)","（B)","計"]
[null,"月　日","～","　　離職日","　月","　 日"," 月　日","～","　　離職日"," 　日",null,null,{"$f":"K24+L24","v":0}]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,"　⑭\n　賃  金  に\n　関  す  る\n　特記事項",null,null,null,null,null,null,null,null,"　□運転免許証　　　　　□個人番号カード\n　□旅券　　　　　　　　□住民票記載事項証明書\n　□国民健康保険被保険者証（健康保険被保険者証）\n　□その他（　　　　　　　　　　　　　　　　　　　　　　　）　"]
[]
[]
[]
[null,"　※公共職業安定所記載欄"]
[null,null,"　⑮欄の記載",null,"□有・□無"]
[null,null,"　⑯欄の記載",null,"□有・□無"]
[null,null,"□資・□聴"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"注意"]
[null,"１．基本手当は受給資格者が、高年齢求職者給付金は高年齢受給資格者が、特例一時金は特例受給資格者が、それぞれ労働の意思及び能力を有するにもかかわらず職業に就くことができない"]
[null,"　ときに支給されるものであること。"]
[null,"２．基本手当、高年齢求職者給付金又は特例一時金の支給を受けようとするときは、住所又は居所を管轄する公共職業安定所又は地方運輸局に出頭し、求職の申し込みをした上、この離職"]
[null,"　票ー２及び離職票ー１（別紙）を提出すること。"]
[null,"３．基本手当、高年齢求職者給付金又は特例一時金の支給を受けないときでも、後日必要な場合があるから、少なくとも4年間は大切に保存すること。"]
[null,"４．この離職票ー2を減失し、又は損傷したときは、交付を受けた公共職業安定所に申し出ること。"]
[null,"※基本手当、高年齢求職者給付金又は特例一時金の受給手続を取られる方は、裏面のⅡ「支給を受けるための手続等」をご覧ください。"]
[]
[null,"⑦離職理由欄・・・離職者の方は、主たる離職理由が該当する理由を１つ選択し、左の離職者記入欄の□の中に〇印を記入の上、下の具体的事情記載欄に具体的事情を記載してください。"]
[null," 【離職理由は所定給付日数・給付制限の有無に影響を与える場合があり、適正に記載してください。】　　"]
[null,"事業主\n記入欄","離職者\n記入欄","離　　　　職　　　　理　　　　由",null,null,null,null,null,null,null,null,null,"※離職区分"]
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[]
[]
[null,null,null,null,"雇 用 保 険 被 保 険 者 離 職 票 ー ２",null,null,null,null,null,null,null,"続紙"]
[null,"様式第６号（２）（第７条関係）"]
[null,"①\n被保険者番号",null,null,null,"　③","フリガナ",null,null,null,null,"　④\n　   離　職\n　   年月日",{"$f":"本紙!M10","v":"00:00:00"}]
[null,"②\n事業所番号",null,null,null,"　離職者氏名"]
[null,"⑤",null,null,null,null,null,null," ⑥\n\n 離   職   者  の\n 住所又は居所",{"$f":"本紙!J12","v":"〒"}]
[null,"               名称"]
[null,"事業所 所在地"]
[null,"         電話番号",null,null,null,null,null,null,null,"電話番号",null,null,null,"－"]
[null,null,null,null,null,null,null,null,null,"※",null,null,"で交付した離職票ー１"]
[null,"住所",null,null,null,null,null,null,null,null,"（交付番号",null,"）に係る賃金支払状況である。"]
[null,"事業主"]
[null,"氏名",null,null,null,null,null,null,null,null,null,"三島公共職業安定所　印"]
[null,"離 職 の 日 以 前 の 賃 金 支 払 状 況 等"]
[null,"⑧ 被保険者期間算定対象期間",null,null,null,"⑨\n⑧の期間\nにおける\n賃金支払\n基礎日数","⑩\n\n             賃 金 支 払 対 象 期 間",null,null,"⑪\n  ⑩ の\n  基 礎\n  日 数","⑫\n　　　　　賃　　　　金　　　　　額",null,null,"⑬\n　 備　考"]
[null,"（A） 一般被保険者等",null,null,"(B) 短期\n雇用特例\n被保険者"]
[null,"離職日の翌日",null,null,null,null,null,null,null,null,"（A)","（B)","計"]
[null,"月　日","～","　　離職日","　月","　 日","月　日","～","　　離職日"," 　日",null,null,{"$f":"K24+L24","v":0}]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,null,"～",null,null,null,null,"～"]
[null,"　⑭\n　賃  金  に\n　関  す  る\n　特記事項",null,null,null,null,null,null,null,null,"　□運転免許証　　　　　□個人番号カード\n　□旅券　　　　　　　　□住民票記載事項証明書\n　□国民健康保険被保険者証（健康保険被保険者証）\n　□その他（　　　　　　　　　　　　　　　　　　　　　　　）　"]
[]
[]
[]
[null,"　※公共職業安定所記載欄"]
[null,null,"　⑮欄の記載",null,"□有・□無"]
[null,null,"　⑯欄の記載",null,"□有・□無"]
[null,null,"□資・□聴"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"注意"]
[null,"１．基本手当は受給資格者が、高年齢求職者給付金は高年齢受給資格者が、特例一時金は特例受給資格者が、それぞれ労働の意思及び能力を有するにもかかわらず職業に就くことができない"]
[null,"　ときに支給されるものであること。"]
[null,"２．基本手当、高年齢求職者給付金又は特例一時金の支給を受けようとするときは、住所又は居所を管轄する公共職業安定所又は地方運輸局に出頭し、求職の申し込みをした上、この離職"]
[null,"　票ー２及び離職票ー１（別紙）を提出すること。"]
[null,"３．基本手当、高年齢求職者給付金又は特例一時金の支給を受けないときでも、後日必要な場合があるから、少なくとも4年間は大切に保存すること。"]
[null,"４．この離職票ー2を減失し、又は損傷したときは、交付を受けた公共職業安定所に申し出ること。"]
[null,"※基本手当、高年齢求職者給付金又は特例一時金の受給手続を取られる方は、裏面のⅡ「支給を受けるための手続等」をご覧ください。"]
[]
[null,"⑦離職理由欄・・・離職者の方は、主たる離職理由が該当する理由を１つ選択し、左の離職者記入欄の□の中に〇印を記入の上、下の具体的事情記載欄に具体的事情を記載してください。"]
[null," 【離職理由は所定給付日数・給付制限の有無に影響を与える場合があり、適正に記載してください。】　　"]
[null,"事業主\n記入欄","離職者\n記入欄","離　　　　職　　　　理　　　　由",null,null,null,null,null,null,null,null,null,"※離職区分"]
[]
[null,"□"]
[null,"□",null,null,null,null,null,null,null,null,null,null,null,null,null,null,1101]
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