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["採択変更申請（届出）（活動組織→地域協議会）"]
["⑲（様式第16号）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"番　　　号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年　月　日"]
[]
[]
["○○地域協議会"]
["　会長　○○　○○"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○○活動組織"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　代表　○○　○○"]
[]
[]
["　　　○年度　里山林活性化による多面的機能発揮対策交付金に係る採択変更申請書（届出書）"]
[]
["　○年○月○日付け第○号で採択通知のあった里山林活性化による多面的機能発揮対策交付金を変更したいので、里山林活性化による多面的機能発揮対策実施要領（令和７年３月31日付け６林整第266号林野庁長官通知）別紙のⅢの第４の５に基づき、下記のとおり里山林活性化による多面的機能発揮対策交付金の採択の変更を申請する（届け出る）。"]
[]
["記"]
[]
["１．活動組織名（法人の場合は末尾に法人番号を括弧書きで記載）"]
[]
[null,"（法人番号：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["２．協定の対象となる森林の位置"]
[]
["３．担当者名・電話番号（連絡がとれる担当者及び電話番号を記載）"]
[]
["４．計画変更の理由"]
[null,"※交付金の増減の場合は金額も併せて記載すること。"]
[]
["５．里山林活性化による多面的機能発揮対策交付金"]
["区分",null,"交付単価等",null,"森林面積等",null,null,null,"交付金額",null,null,null,"都道府県\nの支援額",null,null,null,"市町村\nの支援額",null,null,null,"計"]
["活動推進費",null,"38,000円/年",null,"－",null,null,null,null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円"]
["地域活動型\n（森林資源活用）",null,"120,000円/ha",null,null,null,null,"ha",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円"]
[null,null,"116,000円/ha"]
[null,null,"112,000円/ha"]
["地域活動型\n（竹林資源活用）",null,"332,000円/ha",null,null,null,null,"ha",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"ha"]
[null,null,"304,000円/ha"]
[null,null,"276,000円/ha"]
["複業実践型",null,"191,000円/ha",null,null,null,null,"ha",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"ha"]
[null,null,"176,000円/ha"]
[null,null,"162,000円/ha"]
[null,"安全衛生装備","定額",null,null,null,null,"ha",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円","←複業実践型で定額で支援する安全衛生装備について、"]
["小計",null,"－",null,null,null,null,"ha",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,"要領では様式に盛り込んでおりませんが、運用上、左記のように記載願います。"]
["機能強化",null,"800円/ｍ",null,null,null,null,"ｍ",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円"]
["関係人口創出・\n維持",null,"50,000円/年",null,"－",null,null,null,null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円"]
["資機材等整備",null,"1/2以内",null,null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円"]
[null,null,"1/3以内",null,null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円",null,null,null,"円"]
["計",null,null,null,"－",null,null,null,"円",null,null,null,null,null,null,"円",null,null,null,"円",null,null,null,"円"]
["間伐等（除伐、枝打ちを含む。）の実施面積",null,null,null,null,null,null,"ha"]
["（注１）機能強化は円/m、関係人口創出・維持は円/年を単位とする。"]
["（注２）交付対象とする面積は0.1haを、延長は1mを下限とする。"]
["（注３）地域活動型及び複業実践型の交付単価は、上段から活動１年目、活動２年目、活動３年目の単価とする。"]
["（注４）資機材等整備の森林面積等欄は、金額を記載すること。なお、資機材等整備のうち林内作業車、薪割り機、薪ストーブ又は炭焼き小屋の購入金額若しくは関係人口創出・維持による活動で使用する移動式の簡易なトイレの賃借料は「1/3以内」とする。"]
["（注５）都道府県の支援額、市町村の支援額及び計については、申請時に都道府県や市町村から予定額を聞いている場合等に記載すること。"]
[]
["６．事業費"]
["（注）事業費は、活動推進費、地域活動型、複業実践型、機能強化、関係人口創出・維持、資機材等整備の購入額の合計額とする。"]
[]
["７．月別スケジュール"]
["区分",null,"４","５","６",null,"７",null,"８",null,"９",null,"１０",null,"１１",null,"１２",null,"１",null,"２",null,"３"]
[null,null,"月","月","月",null,"月",null,"月",null,"月",null,"月",null,"月",null,"月",null,"月",null,"月",null,"月"]
["活動推進費"]
[]
["地域活動型\n（森林資源活用）"]
[]
[null,"資源活用の\n取組"]
["地域活動型\n（竹林資源活用）"]
[]
[null,"資源活用の\n取組"]
["複業実践型"]
[]
["機能強化"]
[]
["関係人口創出・\n維持"]
[]
["資機材等整備"]
[]
[]
["８．安全講習等の名称及び内容"]
["講習の名称",null,null,null,"講習の内容",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"実施月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月"]
[]
["９．関係人口創出・維持の相手先及び活動内容"]
["【地域外関係者の相手先名】"]
["【活動内容】"]
["注）地域外関係者との現地確認や活動内容の調整を必ず行うこと。"]
[]
["10．資源活用の取組内容"]
["【活動内容】"]
["注）利用する資源の範囲及び収益の取扱は森林所有者と事前に協議するものとする。"]
[]
["＜施行注意＞\n　　"]
["　　以下の資料を添付すること。","　以下の資料を添付すること。\n　　・活動計画書\n　　・協定書の写し\n　　・活動組織の規約の写し\n　　・農林水産業・食品産業の作業安全のための規範（個別規範：林業）事業者向け チェックシート\n　　・環境負荷低減のクロスコンプライアンスチェックシート等を添付するものとする。\n　記載事項及び添付資料が既に提出している資料の内容と重複する場合には、その重複する部分については省略できることとし、省略するにあたっては、提出済の資料の名称その他資料の特定に必要な情報を記載の上、当該資料と同じ旨を記載することとする。"]