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Discount/surcharge CRS PREMIUM DISCOUNT if return premium mail refund to signature n f i insured payor THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE federal LAW. premium previously paid Excludes Probation Surcharge/ Federal Policy Fee difference SIGNATURE OF INSURed and date SIGNATURE OF INSURANCE AGENT/BROKER DATE MM/DD/YYYY FEMA For.

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