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["附件1："]
["北京市领取社会保险（障）待遇人员资格认证补办表"]
["（    年度）"]
["姓   名",null,null,"性别",null,null,"出生年月"]
["公民身份号码",{"$nulls":5},"参加工作时间"]
["所在单位"]
["领取何种待遇","□ 基本养老金                             ",{"$nulls":3},"□ 伤残津贴、护理费 "]
[null,"□ 工伤人员供养亲属抚恤金                    ",{"$nulls":3},"□ 福利养老金    "]
[null,"□ 城乡居民养老金 "]
["户口所在地地址"]
["现居住地地址"]
["联系电话",{"$nulls":4},"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",{"$nulls":4},"  与领取待遇人员的关系"]
["补办原因"]
[]
[]
[]
[]
["本人签字：           ",{"$nulls":3},"认证部门经办人：                                "]
[{"$nulls":4},"   (认证部门章)"]
[null,"年    月    日",null,null,"                               年    月    日     "]
["备注："]
["说明:  1.本表应如实填写；"]
["2.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；"]
[]
["3.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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