Veterans_BashamForm Number 12A - Revised 1977
Prescribed by State Board of Tax Commissioners
',�VETERANS, OR �iHEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
.. +•
and Aoplication for Deduction From the
Assessed Valua�ion of Taxable Property
�) *** Qualifications On Back *'*
STATE OF INDIANA .X:��C.a.s�X/ COUNTY, •
(Name) /�Q, �, ��yv , being duly s.worn o qa�h say
��T-,�� "�-�"-T r�
�$ )he is years of age; that (s)he resides at
�ll% �S. n �c5�� � � ,
/�L"" ,.��-g y in �(�2� County, Indiana; that (s)he
�� •
Check One: _1� was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S. Armed F"orces
who served during any of its wars -
and who has been honorably discharged therefrom and has a service-
connected disability of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
Pension Certificate or �
Award of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
Department of the Defense Disability Retirement Board of the
appropriate branch of the armed forces
�c.
' exhibited to the County Auditor.
( � �y�� s=��°
IC 6-1. 1-12-13 and 6-1. 1-12-1� �3 o D a
/98�
That this application is made for the purpose of obtaining $�
(not to exceed two thousand dollars) deduction from the assessed valu-
�
ation of the following described taxable property for the year
to W�t: �' a�►a-ig -►o a
TAXING DISTRICT
LEGA�E�C�T� �EY NUMBER
1 9 ��,
� ►o (o-oa8�
That, in addition to the above am'�u�a uction appli�ed
P�IAR 2 1Q�" _.. _
for in this Coun�y, (s)he has or intends to apply for $ deduction
in �i��� County,
f:iJ9IT�R
Taxing District.
--Q� ��.�.G ���'r'=- �
X
(Applicant/Guardian)
Subscribed and sworn to before me, and disability verified this ��':
day of � ��L , 19�a
�
d� D. �
Auaitor °
