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Form Number 12A - Revised 19i7
Prescribed by State Board of Tax Commissioners
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Aoplication for Deduction From the
�, Assessed Valuation of'Taxable Property
*** Qualifications On Bacr ***
STATE OF INDIANA /��Wl-!st COUNTY,
(Name) �(.C� �}-LLa , being duly sworn on o th says
that (s)he is �rZ- years of age; that (s)he resides at
P/u.nu��:y�, in ,�n�- County, Indiana�jOthlat (s)he
Check One: �'was a yember of the U.S. Armed Forces during any of
its wars .
or the widow of a member of the U.S. Armed Forces
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 a�_�a-o7-�03 -oo3.N�8-�8
Award of Compensation or
� Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten perce��� � more from the
Department of the Defense D i ment Board of the
appropriate branch of the a e cE5
*exhibited to the County aua�tor. ���Y 101982
/ 9 p6 ��e �.
IC 6-1. 1-12-13��1 � O,o 0
That this a lication is made for the��TOR I���� 3
pp purpo of obtaining $-y�(j7J
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 0�,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
That,. in addition to the above
for in this County, (s)he has or intends
in
County,
deducGion=applied
apply for $ �, deduction
Taxing District.
X //.�G1M, (/ !l�
Tf�(Applicant/�uardian)
�� Subscribed and sworn to before me, and disability verified this `p
day of � D..� , 19 Se�-
!/{LG a
Auditor