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["附件4："]
["健在确认表（存根）"]
["编号："]
["姓   名",null,"性别",null,"出生日期"]
["国   籍",null,null,"联系电话"]
["提交证件情况","护照号码：",null,"       居留证： □有    □无"]
[null,"离退休证：□有   □无         其他证件："]
["现居住地址"]
["代理人情况\n（限委托办理时填写）","姓名：",null,"证件及号码："]
["填报日期",null,null,"申请人（或   代理人）签名"]
["经办人签名\n（使领馆人员填写）",null,null,"审核人签署\n（使领馆人员填写）"]
["（此处加盖骑缝章）"]
["…………………………………………………………………………………………"]
["出境定居离退休、退职人员健在确认表"]
["编号："]
["姓名",null,"性别",null,"国 籍"]
["出生日期",null,null,"护照号码"]
["联系电话",null,null,"办证情况","□本人申办  □委托办理"]
["离退休地或单位"]
["现居住地地址"]
["确认机构公章："]
[null,null,"日期：         年     月    日"]

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