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&#12403;&#27973;&#21475;&#24066;&#28797;&#23475;&#23550;&#31574;&#26412;&#3=
7096;&#12395;&#12388;&#12356;&#12390;&#12399;&#12289;&#39080;&#27700;&#2347=
5;&#31561;&#23550;&#31574;&#32232;&#31532;&#65298;&#31456;&#31532;&#65297;&=
#31680;&#12300;&#24540;&#24613;&#27963;&#21205;&#20307;&#21046;&#35336;&#30=
011;&#12301;&#12395;&#28310;&#12378;&#12427;&#12290;</p>

<p class=3DMsoPlainText style=3D'punctuation-wrap:simple;text-autospace:non=
e'><span
lang=3DEN-US><o:p>&nbsp;</o:p></span></p>

<h2 style=3D'punctuation-wrap:simple'>&#31532;&#65298;&#12288;&#37197;&#206=
33;&#20307;&#21046;</h2>

<h2 style=3D'punctuation-wrap:simple'>&#65297;&#12288;&#35686;&#25106;&#203=
07;&#21046;</h2>

<p class=3DMsoBodyText2 style=3D'punctuation-wrap:simple'>&#12288;&#28797;&=
#23475;&#23550;&#31574;&#26412;<span
style=3D'color:black'>&#37096;</span>&#12434;&#35373;&#32622;&#12377;&#1242=
7;&#12395;&#12399;&#33267;&#12425;&#12394;&#12356;&#12364;&#12289;&#28797;&=
#23475;&#23550;&#31574;&#12398;&#12383;&#12417;&#12398;&#37197;&#20633;&#12=
434;&#24517;&#35201;&#12392;&#12377;&#12427;&#22580;&#21512;&#12398;&#35686=
;&#25106;&#20307;&#21046;&#12399;&#12289;&#27425;&#12398;&#12392;&#12362;&#=
12426;&#12392;&#12375;&#12289;&#12381;&#12398;&#37197;&#20633;&#12395;&#123=
88;&#12356;&#12390;&#12399;&#12289;&#26412;&#24193;&#12539;&#25903;&#25152;=
&#21336;&#20301;&#12391;&#34892;&#12358;&#12418;&#12398;&#12392;&#12377;&#1=
2427;&#12290;&#12414;&#12383;&#12289;&#25903;&#25152;&#12395;&#12362;&#1235=
6;&#12390;&#12399;&#12289;&#25903;&#25152;&#38263;&#12398;&#21028;&#26029;&=
#12395;&#12424;&#12426;&#12289;&#37197;&#20633;&#20307;&#21046;&#12434;&#12=
392;&#12427;&#12371;&#12392;&#12364;&#12391;&#12365;&#12427;&#12418;&#12398=
;&#12392;&#12377;&#12427;&#12364;&#12289;&#12371;&#12398;&#22580;&#21512;&#=
12289;&#36895;&#12420;&#12363;&#12395;&#12381;&#12398;&#26088;&#12434;&#264=
12;&#24193;&#37197;&#20633;&#36012;&#20219;&#32773;&#12395;&#36890;&#30693;=
&#12375;&#12394;&#12369;&#12428;&#12400;&#12394;&#12425;&#12394;&#12356;&#1=
2290;</p>

<h3 style=3D'margin-bottom:5.0pt;punctuation-wrap:simple'><span lang=3DEN-U=
S>(1)</span>&#12288;&#37197;&#20633;&#22522;&#28310;</h3>

<table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0
 style=3D'margin-left:25.95pt;border-collapse:collapse;border:none;mso-bord=
er-alt:
 solid windowtext .5pt;mso-padding-alt:0mm 4.95pt 0mm 4.95pt;mso-border-ins=
ideh:
 .5pt solid windowtext;mso-border-insidev:.5pt solid windowtext'>
 <tr>
  <td width=3D28 style=3D'width:21.0pt;border:solid windowtext 1.0pt;mso-bo=
rder-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#8470;</p>
  </td>
  <td width=3D420 style=3D'width:315.0pt;border:solid windowtext 1.0pt;bord=
er-left:
  none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windo=
wtext .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#37197;&#12288;&#12288;&#12288;&#20633;&#1=
2288;&#12288;&#12288;&#22522;&#12288;&#12288;&#12288;&#28310;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border:solid windowtext 1.0pt;border=
-left:
  none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windo=
wtext .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#26412;&#24193;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border:solid windowtext 1.0pt;border=
-left:
  none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windo=
wtext .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#37329;&#20809;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border:solid windowtext 1.0pt;border=
-left:
  none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windo=
wtext .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#23492;&#23798;</p>
  </td>
 </tr>
 <tr>
  <td width=3D28 style=3D'width:21.0pt;border:solid windowtext 1.0pt;border=
-top:
  none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid window=
text .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9312;</p>
  </td>
  <td width=3D420 style=3D'width:315.0pt;border-top:none;border-left:none;
  border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window=
text .5pt;
  mso-border-alt:solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 style=3D'margin-top:3.0pt;margin-right:0mm;margin=
-bottom:
  4.0pt;margin-left:0mm;line-height:17.0pt;mso-line-height-rule:exactly'>&#=
38663;&#24230;&#65300;&#20197;&#19978;&#12398;&#22320;&#38663;&#12364;&#303=
30;&#29983;&#12375;&#12383;&#12392;&#12365;&#12290;<span
  style=3D'font-family:"MS Gothic";mso-hansi-font-family:Century'>&#12304;&=
#33258;&#21205;&#37197;&#20633;&#12305;</span></p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
 </tr>
 <tr>
  <td width=3D28 style=3D'width:21.0pt;border:solid windowtext 1.0pt;border=
-top:
  none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid window=
text .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9313;</p>
  </td>
  <td width=3D420 style=3D'width:315.0pt;border-top:none;border-left:none;
  border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window=
text .5pt;
  mso-border-alt:solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 style=3D'margin-top:3.0pt;margin-right:0mm;margin=
-bottom:
  4.0pt;margin-left:0mm;line-height:17.0pt;mso-line-height-rule:exactly'>&#=
27941;&#27874;&#20104;&#22577;&#65288;&#27880;&#24847;&#22577;&#12289;&#356=
86;&#22577;&#65289;&#12364;&#30330;&#34920;&#12373;&#12428;&#12383;&#12392;=
&#12365;&#12290;<span
  style=3D'font-family:"MS Gothic";mso-hansi-font-family:Century'>&#12304;&=
#33258;&#21205;&#37197;&#20633;&#12305;</span></p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
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r-alt:
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  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
 </tr>
 <tr>
  <td width=3D28 style=3D'width:21.0pt;border:solid windowtext 1.0pt;border=
-top:
  none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid window=
text .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9314;</p>
  </td>
  <td width=3D420 style=3D'width:315.0pt;border-top:none;border-left:none;
  border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window=
text .5pt;
  mso-border-alt:solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 style=3D'margin-top:3.0pt;margin-right:0mm;margin=
-bottom:
  4.0pt;margin-left:0mm;line-height:17.0pt;mso-line-height-rule:exactly'>&#=
21508;&#25903;&#25152;&#12424;&#12426;&#35686;&#25106;&#20307;&#21046;&#124=
34;&#12392;&#12387;&#12383;&#26088;&#12398;&#36890;&#30693;&#12364;&#12354;=
&#12387;&#12383;&#12392;&#12365;&#12290;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
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r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
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r-alt:
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  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:-5.25pt;
  margin-bottom:4.0pt;margin-left:-5.25pt;mso-para-margin-top:3.0pt;mso-par=
a-margin-right:
  -.5gd;mso-para-margin-bottom:4.0pt;mso-para-margin-left:-.5gd;text-align:
  center;line-height:17.0pt;mso-line-height-rule:exactly'>&#65288;&#9675;&#=
65289;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
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r-alt:
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  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:-5.25pt;
  margin-bottom:4.0pt;margin-left:-5.25pt;mso-para-margin-top:3.0pt;mso-par=
a-margin-right:
  -.5gd;mso-para-margin-bottom:4.0pt;mso-para-margin-left:-.5gd;text-align:
  center;line-height:17.0pt;mso-line-height-rule:exactly'>&#65288;&#9675;&#=
65289;</p>
  </td>
 </tr>
 <tr style=3D'mso-yfti-lastrow:yes'>
  <td width=3D28 style=3D'width:21.0pt;border:solid windowtext 1.0pt;border=
-top:
  none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid window=
text .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9315;</p>
  </td>
  <td width=3D420 style=3D'width:315.0pt;border-top:none;border-left:none;
  border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid window=
text .5pt;
  mso-border-alt:solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 style=3D'margin-top:3.0pt;margin-right:0mm;margin=
-bottom:
  4.0pt;margin-left:0mm;line-height:17.0pt;mso-line-height-rule:exactly'><s=
pan
  style=3D'letter-spacing:-.35pt'>&#12381;&#12398;&#20182;&#12289;&#22823;&=
#35215;&#27169;&#12394;&#28797;&#23475;&#12364;&#30330;&#29983;&#21448;&#12=
399;&#20999;&#36843;&#12375;&#12289;&#24066;&#38263;&#12364;&#24517;&#35201=
;&#12392;&#35469;&#12417;&#12383;&#12392;&#12365;&#12290;<span
  lang=3DEN-US><o:p></o:p></span></span></p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
  <td width=3D42 style=3D'width:31.5pt;border-top:none;border-left:none;bor=
der-bottom:
  solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top=
-alt:
  solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-borde=
r-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#9675;</p>
  </td>
 </tr>
</table>

<h3 style=3D'margin-top:5.0pt;margin-right:0mm;margin-bottom:5.0pt;margin-l=
eft:
21.0pt;punctuation-wrap:simple'><span lang=3DEN-US>(2)</span>&#12288;&#3719=
7;&#20633;&#20869;&#23481;</h3>

<table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0
 style=3D'margin-left:25.95pt;border-collapse:collapse;border:none;mso-bord=
er-alt:
 solid windowtext .5pt;mso-padding-alt:0mm 4.95pt 0mm 4.95pt;mso-border-ins=
ideh:
 .5pt solid windowtext;mso-border-insidev:.5pt solid windowtext'>
 <tr>
  <td width=3D98 style=3D'width:73.5pt;border:solid windowtext 1.0pt;mso-bo=
rder-alt:
  solid windowtext .5pt;padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 style=3D'margin-left:0mm;line-height:17.0pt;mso-l=
ine-height-rule:
  exactly'><span lang=3DEN-US><o:p>&nbsp;</o:p></span></p>
  </td>
  <td width=3D476 style=3D'width:357.0pt;border:solid windowtext 1.0pt;bord=
er-left:
  none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windo=
wtext .5pt;
  padding:0mm 4.95pt 0mm 4.95pt'>
  <p class=3DMsoBodyText3 align=3Dcenter style=3D'margin-top:3.0pt;margin-r=
ight:0mm;
  margin-bottom:4.0pt;margin-left:0mm;text-align:center;line-height:17.0pt;
  mso-line-height-rule:exactly'>&#37197;&#12288;&#12288;&#12288;&#20633;&#1=
2288;&#12288;&#12288;&#20154;&#12288;&#12288;&#12288;&#21729;</p>
  </td>
 </tr>
 <tr style=3D'height:163.45pt'>
  <td width=3D98 style=3D'width:73.5pt;border:solid windowtext 1.0pt;border=
-top:
  none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid window=
text .5pt;
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