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大野城市長 様

受任者

大野城市曙町二 目 番 大野城市長 井本 宗

私 上記 者を代理人 定 次 権限を委任します

母子保健法第21条 4に基づく未熟児養育医療費 自己負担金に係る子

医療費 受領 未熟児養育医療費自己負担金へ 充当に関する 切 権限

成 月 日

委任者 養育医療給付申請者

住 所 大野城市

氏 名

子 医療証 受給者番

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