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["附件2："]
["北京市领取社会保险（障）待遇人员资格认证代理表\n(     年度)"]
["领取待遇人员基础信息："]
["公民身份号码",{"$nulls":3},"姓   名"]
["性  别",null,"民族",null,"出生日期 "]
["领取待遇人员通讯信息："]
["领取何种待遇","□ 基本养老金  ",null,null,"    □ 伤残津贴、护理费 "]
[null,"□ 工伤人员供养亲属抚恤金",null,null,"    □ 福利养老金 "]
[null,"□ 城乡居民养老金 "]
["户口所在地地址"]
["户口所在地邮编"]
["现居住地地址"]
["现居住地邮编",null,null,"联系电话"]
["代理人信息："]
["姓  名",{"$nulls":3},"性别"]
["公民身份号码"]
["联系电话 ",null,null,"与领取待遇人员的关系"]
["声      明"]
["领取待遇人员声明",{"$nulls":3},"代理人声明"]
["本人因 □生病住院 □居家治疗 □行动不便，不能亲"]
["自办理北京市领取社会保险（障）待遇资格认证,特委",{"$nulls":3},"本人受             委托代理"]
["托         作为我的合法代理人，全权代表本人办理",{"$nulls":3},"北京市领取社会保险（障）待"]
["北京市领取社会保险（障）待遇资格认证。",{"$nulls":3},"遇资格认证。"]
["领取待遇人员签字：",{"$nulls":3},"代理人签字："]
[" 年    月    日 ",{"$nulls":3}," 年    月    日 "]
["注明：1.本表应如实填写；"]
["      2.与领取待遇人员的关系：父母、子女、配偶、兄弟姐妹、祖父母、外祖父母、孙子女、外"]
["        孙子女、其他亲属、法定代理人、其他。"]

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