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["苗栗縣身心障礙鑑定暨需求評估異議書"]
[]
["基本資料欄\n異 議 人",null,"姓      名","                □（簽章）                                       ",{"$nulls":4},"填寫日期",null,"          年      月      日  "]
[null,null,"國民身分證\n統 一 編 號"]
[null,null,"聯絡電話"]
["異議事項",null,"□身心障礙類別/等級異議複檢"]
[null,null,"□福利與服務需求評估異議複評"]
["異議理由",null,"以下請就您個人困難說明您異議理由："]
["復審結果",null,"□維持原核定結果"]
[null,null,"□建議撤銷原核定結果，核列_______________________________"]
[null,null,"理由如下："]
[]
[]
[]
[]
[]
[]
["核章",null,"承辦人",null,"科長",null,null,"單位主管"]

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