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["令和３年度住宅・建築物環境対策事業費補助金応募・交付申請書"]
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[null,"　以下の内容により、既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）の応募・交付を申請します。"]
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[null,"１．補助事業\n　　の名称",{"$nulls":4},"既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）"]
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[null,"３．提案種別\n （いずれかを選択）",{"$nulls":4},"□",null,null,"通常補助（補助率１／３以内）として申請"]
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[null,"４．補助対象\n　　事業費",{"$nulls":23},"千円（端数切り捨て）"]
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[null,"５．補助\n　　申請額",{"$nulls":23},"千円（端数切り捨て）"]
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[null,"６．補助\n　　対象\n　　物件",null,null,"1）棟　数",{"$nulls":6},"合計",{"$nulls":5},"棟"]
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[{"$nulls":11},"ﾌﾘｶﾞﾅ"]
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[{"$nulls":6},"連絡先",{"$nulls":4},"電話番号又はメールアドレス"]
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[{"$nulls":6},"属性\n（いずれかを選択）",{"$nulls":4},"□",null,"建築主（建物所有者）"]
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[null,"事務代行者\n（注２）",{"$nulls":4},"法人名\nまたは\n氏名",{"$nulls":4},"ﾌﾘｶﾞﾅ"]
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[null,null,"(注１)","事務代行者がいる場合、法人名又は氏名を記載してください。"]
[null,null,"(注２)","事務代行者は代表提案者になることはできません。"]

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[null,"　以下の内容により、既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）の応募・交付を申請します。"]
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[null,"１．補助事業\n　　の名称",{"$nulls":4},"既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）"]
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[null,"２．事業名"]
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[null,"３．提案種別\n （いずれかを選択）",{"$nulls":4},"□",null,null,"通常補助（補助率１／３以内）として申請"]
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[null,"４．補助対象\n　　事業費",{"$nulls":23},"千円（端数切り捨て）"]
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[null,"６．補助\n　　対象\n　　物件",null,null,"1）棟　数",{"$nulls":6},"合計",{"$nulls":5},"棟"]
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[null,null,"(注１)","事務代行者がいる場合、法人名又は氏名を記載してください。"]
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["注2）",null,null,"実施計画の概要：予定棟数、金額等を記載してください。"]
[null,null,null,"なお、補助対象事業費、補助申請額は合計額とし、様式３－１、様式３－２と金額が一致するように"]
[null,null,null,"記載してください。"]

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["※応募する建物が１棟のみの場合は提出の必要はありません。"]
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["建物５",null,null,null,"建物名"]
[{"$nulls":4},"所在地"]
[{"$nulls":4},"建築概要",null,null,null,"延床面積",{"$nulls":7},"㎡",null,"階数",null,null,"地上",{"$nulls":4},"階",null,"地下",{"$nulls":4},"階"]
[{"$nulls":4},"建物用途\n（選択）",null,null,null,"□","戸建住宅",null,null,null,"□","共同住宅",null,null,null,"□","事務所等",null,null,null,"□","ホテル等",null,null,null,"□","病院等"]
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["建物６",null,null,null,"建物名"]
[{"$nulls":4},"所在地"]
[{"$nulls":4},"建築概要",null,null,null,"延床面積",{"$nulls":7},"㎡",null,"階数",null,null,"地上",{"$nulls":4},"階",null,"地下",{"$nulls":4},"階"]
[{"$nulls":4},"建物用途\n（選択）",null,null,null,"□","戸建住宅",null,null,null,"□","共同住宅",null,null,null,"□","事務所等",null,null,null,"□","ホテル等",null,null,null,"□","病院等"]
[{"$nulls":8},"□","百貨店等",null,null,null,"□","学校等",null,null,null,"□","飲食店等",null,null,null,"□","集会所等",null,null,null,"□","工場等"]
["建物７",null,null,null,"建物名"]
[{"$nulls":4},"所在地"]
[{"$nulls":4},"建築概要",null,null,null,"延床面積",{"$nulls":7},"㎡",null,"階数",null,null,"地上",{"$nulls":4},"階",null,"地下",{"$nulls":4},"階"]
[{"$nulls":4},"建物用途\n（選択）",null,null,null,"□","戸建住宅",null,null,null,"□","共同住宅",null,null,null,"□","事務所等",null,null,null,"□","ホテル等",null,null,null,"□","病院等"]
[{"$nulls":8},"□","百貨店等",null,null,null,"□","学校等",null,null,null,"□","飲食店等",null,null,null,"□","集会所等",null,null,null,"□","工場等"]
["建物８",null,null,null,"建物名"]
[{"$nulls":4},"所在地"]
[{"$nulls":4},"建築概要",null,null,null,"延床面積",{"$nulls":7},"㎡",null,"階数",null,null,"地上",{"$nulls":4},"階",null,"地下",{"$nulls":4},"階"]
[{"$nulls":4},"建物用途\n（選択）",null,null,null,"□","戸建住宅",null,null,null,"□","共同住宅",null,null,null,"□","事務所等",null,null,null,"□","ホテル等",null,null,null,"□","病院等"]
[{"$nulls":8},"□","百貨店等",null,null,null,"□","学校等",null,null,null,"□","飲食店等",null,null,null,"□","集会所等",null,null,null,"□","工場等"]
["注）記入欄が不足する場合は、適宜、コピーして使用してください。"]

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[{"$nulls":5},"（様式３-１・通常補助）"]
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["１．事業計画"]
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["１．省エネ診断に要する費用",null,null,"1/3"]
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["３．省エネ性能表示に要する費用",null,null,"1/3"]
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["２．補助対象事業費の内訳"]
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["１．省エネ診断に要する費用"]
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{"$rows_empty":7}
["小計　ｃ"]
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["注１）消費税等は除いた額を記載してください。"]
["注２）それぞれの項目にて、千円未満は切り捨てとして、金額を記載してください。"]
["注３）複数建築物を対象とする事業で、単価が異なる場合など、適宜、項目を区分して記載してください。"]
["注４）備考欄には、建築物の種別、表示の内容などを記載してください。"]

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["１．事業計画"]
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["１．省エネ診断に要する費用",null,null,"10/10"]
["２．第三者認証等に要する費用",null,null,"10/10"]
["３．省エネ性能表示に要する費用",null,null,"10/10"]
["合計"]
[]
["２．補助対象事業費の内訳"]
["項目",null,"単価\n（単位：千円）","棟数","補助対象事業費\n（単位：千円）","備考"]
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["１．省エネ診断に要する費用"]
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["３．省エネ性能表示に要する費用"]
{"$rows_empty":7}
["小計　ｃ"]
[]
["注１）消費税等は除いた額を記載してください。"]
["注２）それぞれの項目にて、千円未満は切り捨てとして、金額を記載してください。"]
["注３）複数建築物を対象とする事業で、単価が異なる場合など、適宜、項目を区分して記載してください。"]
["注４）備考欄には、建築物の種別、表示の内容などを記載してください。"]

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["審査基準に関する事項 － 省エネ性能表示の普及に関する取り組み内容：その１"]
["【定額補助として申請する場合のみ提出】"]
[]
["事業名",{"$nulls":14},"代表提案者"]
[]
["１．省エネ性能表示（評価書、プレート等による表示）の実施計画"]
["主たる建物用途\n（具体的に記載して\nください）",{"$nulls":4},"使用形態\n（持ち家・\n賃貸・自社\n使用の別）",null,null,null,"表示方法",{"$nulls":4},"実施棟数（棟）"]
[{"$nulls":14},"ＢＥＬＳ",null,null,null,"ｅマーク",null,null,null,"その他",null,null,null,"合計"]
[]
[]
[]
["合計"]
[]
["２．省エネ性能表示の普及に資する取り組みの波及効果"]
[]
["波及効果\n（人／年間）",{"$nulls":4},"波及効果の根拠"]
[{"$nulls":5},"対象人数\n(人)[A]",null,null,"効果率\n(%)[B]",null,null,"波及見込み人数(人)\n[C]=A×B",null,null,"取り組み内容、対象人数の根拠、効果率の根拠等"]
["□","見せる"]
[0,{"$nulls":10},0]
[{"$nulls":11},0]
["（人／年間）",{"$nulls":10},0]
["□","学習"]
[0,{"$nulls":10},0]
[{"$nulls":11},0]
["（人／年間）",{"$nulls":10},0]
["□","その他の特記すべき取り組み　（波及効果として人数に換算することが難しい取り組みなど）"]

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[{"$nulls":35},"（様式４-２・定額補助）"]
["審査基準に関する事項 － 省エネ性能表示の普及に関する取り組み内容：その２"]
["【定額補助として申請する場合のみ提出】"]
[]
["事業名",{"$nulls":18},"代表提案者"]
["取り組み\n単位",null,null,null,"□","特定の建築物",{"$nulls":13},"１棟又は複数棟で実施"]
[{"$nulls":4},"□","特定の地域",{"$nulls":13},"街区・エリア単位など、複数棟でまとめて実施"]
[{"$nulls":4},"□","事業者単位",{"$nulls":13},"エリア限定なし（全国、所有物件）の複数棟にて実施"]
[{"$nulls":4},"□","その他",null,null,"（内容：",{"$nulls":26},"）"]
["■全体概要"]
{"$rows_empty":28}
["■実施体制"]
{"$rows_empty":20}
["注）本様式（様式４－２）は、採択後にホームページ等で情報公開することを予定しています。"]

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[{"$nulls":13},"別添５"]
[]
["令和３年度既存建築物省エネ化推進事業"]
["（省エネルギー性能の診断・表示に対する支援）"]
["補助事業に関する宣誓書"]
[]
[]
[null,"本補助事業において、申請者が以下の（1）～（3）のいずれかに該当する関係会社等"]
[]
[null,"からの調達（他の会社を経由した場合、いわゆる下請会社の場合も含む。）の有無に"]
[]
[null,"ついて、該当する項目にチェックを入れてください。"]
[]
[null,null,"（1）","100％同一の資本に属するグループ企業"]
[]
[null,null,"（2）","補助事業者の関係会社（財務諸表等の用語、様式及び作成方法に関する"]
[null,null,null,"規則第８条第８項で定めるもの。前号に定める者を除く。）"]
[]
[null,null,"（3）","補助事業者の役員である者（親族を含む）又はこれらの者が役員に"]
[null,null,null,"就任している法人"]
[]
[null,"1）（1）～(3）の関係にある会社からの調達は一切ない。　　☐",{"$nulls":9},"□"]
[]
[null,"2）（1）～(3）の関係にある会社からの調達がある。　　　　☐",{"$nulls":9},"□"]
[]
[]
[]
[null,"【（1）～（3）の関係にある会社からの調達がある場合 】　※上記2)の場合"]
[]
[null,"　　①価格の妥当性等を確保するため、３者以上からの見積り結果を交付申請に"]
[null,null,"添付してください。"]
[]
[null,"　　②協議会は、前項により提出された見積り結果について、調達費用の妥当性を"]
[null,null,"確認します。"]
[]
[null,"　　③申請者は代表提案者及び委託契約者の連名として、交付申請してください。"]
[]
[]
[null,"　本確認書に虚偽の記載をし、記載内容が事実と相違していることが発覚した場合は、"]
[null,"補助金の全額返還となることについて確認しました。"]
[]
[{"$nulls":10},"令和　　年　　月　　日"]
[]
[null,"事業名"]
[]
[]
["　 （代表提案者）"]
[null,"法人の場合","法人名",null,"ﾌﾘｶﾞﾅ"]
[]
[null,null,"代表者名",null,"部署名",{"$nulls":5},"役職名"]
[{"$nulls":4},"ﾌﾘｶﾞﾅ"]
[]
[null,"個人の　場合","氏名",null,"ﾌﾘｶﾞﾅ"]

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[{"$nulls":9},"別添６"]
[]
["令和３年度既存建築物省エネ化推進事業"]
["（省エネルギー性能の診断・表示に対する支援）"]
["申請の制限に係る事案の有無等の確認書"]
[]
[" １．申請の制限に係る事案について"]
[null,"　令和３年度既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）"]
[null,"補助金交付規程第５第２項に基づき、過去３カ年度内に国土交通省住宅局所管事業補助金に"]
[null,"おける同規定第１３（交付決定の取り消し）に相当する理由での補助金の返還の有無につい"]
[null,"て以下の通り申告を求めます。なお、該当する事案がある場合には、本補助金への申請が原"]
[null,"則として制限されます。"]
[]
[null," 上記１の申請の制限に係る事案の有無について",{"$nulls":4},"□","有","□","無"]
[]
[null," 補助事業者の名称"]
[null," 事業名"]
[null," 返還命令日"]
[null," 返還日"]
[null," 返還額（円）"]
[null," 返還事由"]
[]
[" ２．暴力団及び暴力団員の排除について"]
["  ","　令和３年度既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）"]
[null,"補助金交付規程第５第３項に基づき、当該申請を制限される者への該当の有無について申告"]
[null,"を求めます。なお、該当がある場合は、本補助金への申請を制限されます。"]
[]
[null," 上記２の申請の制限に係る事案の有無について",{"$nulls":4},"□","有","□","無"]
[]
[" ３．個人情報の使用について"]
["  ","　令和３年度既存建築物省エネ化推進事業（省エネルギー性能の診断・表示に対する支援）"]
[null,"補助金交付規程第１３（交付決定の取り消し）に該当した場合には、本申請に係る個人情報"]
[null,"について他府省庁・独立行政法人を含む他の補助金担当課に当該返還事案の概要（法人又は"]
[null,"申請者名・補助金名・交付決定額・補助事業の実施期間・返還を生じた理由・講じられた措"]
[null,"置の内容等）を提供することがあります。"]
[]
[null," 上記３の内容について",{"$nulls":4},"□","　同意する"]
[]
[null,"※補助事業者の名称には法人・団体等の名称（個人の場合は氏名）を記入してください。"]
[null,"※本補助金の交付後に１及び２の内容に虚偽等が存することが判明した場合には、本補助金"]
[null,"  の返還を求めることがあります。"]
[null,"　"]
[null,"　本確認書の内容について誤りはなく、事実と相違していることが発覚した場合は、"]
[null,"本補助金の全額返還となることがあることについて確認しました。"]
[]
[{"$nulls":5},"令和　　年　　月　　日"]
[null,"　　事業名："]
[null,"代表提案者："]

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[{"$nulls":22},"別添７"]
[]
[{"$nulls":15},"令和　　年　　月　　日"]
[]
[]
["振込口座登録票"]
[]
[]
["１．銀行名",{"$nulls":14},"銀行"]
[]
[null,"銀行コード"]
[]
["２．支店名",{"$nulls":14},"支店"]
[]
[null,"支店コード"]
[]
["３．預金種別（該当する種別を○で囲んでください）"]
[]
[{"$nulls":5},"普　通",null,"・","当　座",null,"・","貯　蓄",null,"・","その他"]
[]
["４．口座番号"]
[]
[]
["５．郵便番号及び住所"]
[null,"１）郵便番号",null,null,null,"〒"]
[null,"２）住　　所："]
[]
[]
[{"$nulls":4},"注）住所は、都道府県名から記載してください。"]
[]
["６．","カ　ナ："]
[]
[]
[null,"口座名："]
[]
[]
[{"$nulls":5},"事業名："]
[{"$nulls":5},"代表提案者："]

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[{"$nulls":10},"任意様式１"]
["委 任 状"]
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["事務代行者"]
[null,"会社名"]
[null,"役職・代表者名",{"$nulls":7},"印"]
[null,"住所",null,"〒"]
[]
[]
[]
[]
["　私は上記の者を交付申請書等の問い合わせ先となることを定め、令和３年度既存建築"]
["物省エネ改修事業（省エネルギー性能の診断・表示に対する支援）補助金の交付申請書"]
["等に関する問い合わせ先となることの権限を委任します。"]
[]
[{"$nulls":7},"令和　年　月　日　"]
[]
["委任者（代表提案者）"]
[null,"会社名"]
[null,"役職・代表者名",{"$nulls":7},"印"]
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[{"$nulls":8},"任意様式２"]
[]
["令和３年度既存建築物省エネ化推進事業\n（省エネルギー性能の診断・表示に対する支援）における\n共同事業実施規約"]
[]
["事業名："]
["建物名："]
[]
["甲（代表提案者）："]
["乙（建物所有者）："]
[]
[]
["（補助金交付への協力）"]
["　第１条","　甲と乙は、令和３年度既存建築物省エネ化推進事業費補助金（省エネルギー性能の診断・表示に対する支援）（以下「本補助金」という。）の交付を受けるための所要の手続きを、両者協力して共同で行うことを確認する。"]
[]
[]
[]
["（交付申請等）"]
["　第２条","　本補助金の申請から受領に要する諸手続については、甲及び乙を代表して甲が行うものとする。"]
[]
[]
["（補助金の受領）"]
["　第３条","　本補助金の受領については甲が受領するものとし、乙はこれを異議なく承諾する。"]
[]
["（取得財産の管理等について）"]
["　第４条","　甲と乙は、本補助事業の完了後においても善良な管理者の注意をもって管理し（善管注意義務）、本補助金の交付の目的に従ってその効率的運用を行うことを確認する。また、５年以内に承認を受けないで補助金の交付の目的に反して使用し、譲渡し、交換し、貸付し、担保に供し、又は取壊しすることができないことを確認する。"]
[]
[]
[]
[]
[]
["規約締結の証として、本書２通を作成し、甲乙署名・捺印のうえ、各自１通を保有する。"]
[]
[]
[{"$nulls":8},"令和　　年　　月　　日"]
[]
[null,null,"甲（代表提案者）："]
[]
[{"$nulls":8},"印"]
[]
[null,null,"乙（建物所有者）："]
[]
[{"$nulls":8},"印"]

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[{"$nulls":21},"（別添様式・通常補助）"]
["提出書類のチェック表（１）"]
[]
["１．通常補助（補助率１／３）として申請の場合"]
["様式",null,"タイトル",{"$nulls":5},"主なチェック項目",{"$nulls":12},"確認"]
["様式1",null,"　応募・交付申請書",{"$nulls":5},"提案種別で「通常補助」を選択しているか",{"$nulls":12},"□"]
["（関係会社の場合は様式1-2）",{"$nulls":7},"記載事項に漏れはないか",{"$nulls":12},"□"]
["様式2-1",null,"　フェイスシート",{"$nulls":5},"記載事項に漏れはないか",{"$nulls":12},"□"]
[{"$nulls":8},"事務連絡先の住所、電話番号、Ｅ-mailアドレス等に間違いはないか",{"$nulls":12},"□"]
[{"$nulls":8},"実施計画に記載する「補助対象事業費」「補助申請額」が様式３－１の合計額と一致しているか",{"$nulls":12},"□"]
["様式2-2",null,"　補助事業の実施場所の概要\n　(複数棟で実施の場合のみ)",{"$nulls":5},"実施予定の建物毎に、建物概要を記載しているか",{"$nulls":12},"□"]
["様式3-1",null,"　事業計画及び補助申請額",{"$nulls":5},"消費税を除く額として記載しているか",{"$nulls":12},"□"]
[{"$nulls":8},"各費用は千円未満切り捨てとして記載しているか",{"$nulls":12},"□"]
["別添5",null,"　補助事業に関する宣誓書",{"$nulls":18},"□"]
["別添6",null,"　申請の制限に係る事案の\n　有無等に関する確認書",{"$nulls":18},"□"]
["別添7",null,"　口座登録票",{"$nulls":5},"口座情報に間違いはないか",{"$nulls":12},"□"]
["原本写し",null,"　補助対象事業費の見積書",{"$nulls":5},"内訳が記載されているか。また、補助対象外の項目については、手書きにて「補助対象外」と追記。",{"$nulls":12},"□"]
["原本",null,"　代表提案者の登記簿等\n　事業実態の分かる書類",{"$nulls":5},"申請日より３か月以内の原本で提出すること。",{"$nulls":12},"□"]
["任意様式1",null,"　委任状",{"$nulls":5},"事務代行者に委任する場合は提出",{"$nulls":12},"□"]
["任意様式2",null,"　共同事業実施規約",{"$nulls":5},"対象者のみ",{"$nulls":12},"□"]
["任意様式3",null,"　その他確認に必要と\n　思われるもの",{"$nulls":18},"□"]
["別添様式",null,"　提出書類のチェック表",{"$nulls":5},"提出書類に不備がないように再度チェックをお願いします。\nこのチェック表をファイルの一番上に綴じてご提出ください。",{"$nulls":12},"□"]

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[{"$nulls":21},"（別添様式・定額補助）"]
["提出書類のチェック表（２）"]
[]
["２．定額補助（波及効果が高いものとして評価を受ける）として申請の場合"]
["様式",null,"タイトル",{"$nulls":5},"主なチェック項目",{"$nulls":12},"確認"]
["様式1",null,"　応募・交付申請書",{"$nulls":5},"提案種別で「定額補助」を選択しているか",{"$nulls":12},"□"]
["（関係会社の場合は様式1-2）",{"$nulls":7},"記載事項に漏れはないか",{"$nulls":12},"□"]
["様式2-1",null,"　フェイスシート",{"$nulls":5},"記載事項に漏れはないか",{"$nulls":12},"□"]
[{"$nulls":8},"事務連絡先の住所、電話番号、Ｅ-mailアドレス等に間違いはないか",{"$nulls":12},"□"]
[{"$nulls":8},"実施計画に記載する「補助対象事業費」「補助申請額」が様式３－２の合計額と一致しているか",{"$nulls":12},"□"]
["様式2-2",null,"　補助事業の実施場所の概要\n　(複数棟で実施の場合のみ)",{"$nulls":5},"実施予定の建物毎に、建物概要を記載しているか",{"$nulls":12},"□"]
["様式3-2",null,"　事業計画及び補助申請額",{"$nulls":5},"消費税を除く額として記載しているか",{"$nulls":12},"□"]
[{"$nulls":8},"各費用は千円未満切り捨てとして記載しているか",{"$nulls":12},"□"]
["様式4-1",null,"　省エネ性能の普及に\n　関する取り組み内容\n （その１、その２）",{"$nulls":5},"必要な項目を選択または記載しているか",{"$nulls":12},"□"]
["様式4-2",{"$nulls":7},"各項目で「その他」を選択した場合、内容を記載しているか",{"$nulls":12},"□"]
[{"$nulls":8},"波及効果の人数、根拠等を記載しているか",{"$nulls":12},"□"]
[{"$nulls":8},"全体概要に、スケジュールを含め、具体的な取り組みイメージがわかりやすくまとめられているか",{"$nulls":12},"□"]
[{"$nulls":8},"実施体制に、省エネ性能表示を普及する対象者を含めて図示しているか",{"$nulls":12},"□"]
["別添5",null,"　補助事業に関する宣誓書",{"$nulls":18},"□"]
["別添6",null,"　申請の制限に係る事案の\n　有無等に関する確認書",{"$nulls":18},"□"]
["別添7",null,"　口座登録票",{"$nulls":5},"口座情報に間違いはないか",{"$nulls":12},"□"]
["原本写し",null,"　補助対象事業費の見積書",{"$nulls":5},"内訳が記載されているか。また、補助対象外の項目については、手書きにて「補助対象外」と追記。",{"$nulls":12},"□"]
["原本",null,"　代表提案者の登記簿等\n　事業実態の分かる書類",{"$nulls":5},"申請日より３か月以内の原本で提出すること。",{"$nulls":12},"□"]
["任意様式1",null,"　委任状",{"$nulls":5},"事務代行者に委任する場合は提出",{"$nulls":12},"□"]
["任意様式2",null,"　共同事業実施規約",{"$nulls":5},"対象者のみ",{"$nulls":12},"□"]
["任意様式3",null,"　その他確認に必要と\n　思われるもの",{"$nulls":18},"□"]
["別添様式",null,"　提出書類のチェック表",{"$nulls":5},"提出書類に不備がないように再度チェックをお願いします。\nこのチェック表をファイルの一番上に綴じてご提出ください。",{"$nulls":12},"□"]