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Any person who knowingly , with intent to defraud any insurance company or other person , files <br /> an <br /> application of insurance containing any materially false information or conceals for the purpose <br /> of <br /> misleading , information concerning any fact material thereto commits a fraudulent insurance act , which is <br /> a crime . <br /> Deposit of $ 0 . 00 is enclosed to apply to the first premium payment under the Policy , if issued . <br /> Signed at : Date : November 18 , 2003 <br /> Applicant : Indi . n River Couqky Board of County Commissioners <br /> flAngal Name ) <br /> Signed bKenneth R . Macht , Chairman <br /> jr (Officer's Name and Title ) <br /> Agency Name : Ch 0tkrNiE <br /> Agent's Signature : . <br /> CLVA� <br /> PROVED : <br /> A - 8cA QA <br /> 07 <br /> 04 C,7-; C my AdIninistrator <br /> APPAO As YO FORM <br /> AN L SUFFtCIE <br /> By <br /> ARIAN E . FELL <br /> A ISTANT COUNTY ATTORNEY <br /> LG 1320 10/02 4 <br />