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Get AR AR1000RC5 2018

Ntal disability by a licensed physician, a licensed psychologist, or a licensed psychological examiner. I certify that the information listed above is true and correct. Date of Birth Initial Diagnosis Date Doctor or Examiner s Signature Date Doctor or Examiner s Name Telephone Number Street Address AR1000RC5 (R 7/2/2018) City Taxpayer s Signature State Zip Date.

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