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["附件3："]
["北京市领取社会保险（障）待遇异地居住人员资格认证表"]
["（      年度）"]
["姓   名",null,null,"性别",null,null,"出生年月",{"$nulls":3},"近 期\n一 吋\n照 片"]
["公民身份号码"]
["所在单位",{"$nulls":5},"参加工作时间"]
["领取何种待遇","□基本养老金                                ",{"$nulls":4},"□伤残津贴、护理费"]
[null,"□工亡人员供养亲属抚恤金                          ",{"$nulls":4},"□福利养老金"]
[null,"□城乡居民养老金              "]
["户口所在地地址"]
["现居住地地址"]
["联系电话",{"$nulls":6},"邮政编码"]
["身体状况","□健康         □一般         □常年有病        □ 生活不能自理"]
["认证方式","□本人认证       □代理认证"]
["代理人情况\n（限委托办理时填写）","姓 名",null,null,"性别",null,"公民身份号码"]
[null,"联系电话",{"$nulls":4},"  与领取待遇人员的关系"]
["本人签字："]
["                                                               年    月    日"]
["协助认证的街道(乡/镇)劳动保障部门核查意见",{"$nulls":4},"协助认证的区(县)及以上社保经办机构核查意见"]
["经办人:",{"$nulls":4},"经办人:"]
[]
["负责人：",{"$nulls":4},"负责人："]
["                            (加盖公章)",{"$nulls":4},"                        (加盖公章)"]
["联系电话：",{"$nulls":4},"联系电话：                          "]
["                        年    月    日",{"$nulls":4},"                       年    月    日"]
["备注："]
["说明： 1.本表应如实填写，本人签字后，请在规定的认证结束日前寄回发表单位；"]
["               2. 对逾期不办理认证的，按暂时失去领取社会保险（障）待遇资格处理；"]
["               3.领取待遇人员生病住院、居家治疗或行动不便的，其亲属可代为办理领取待遇资格认证；凡连续两年采取代"]
["                 办领取待遇资格认证的，第三年本人必须和居住地认证机构进行面对面地认证；"]
["              4.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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