Veterans_Cloin"'" APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
YVWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
.`- '- State Farm 12662 (R11 I 1POB)
S Presaibed by �ha Departmerit d L.oml Govemment Finance
�STRUCTIONS: Please check appropriate box(es) peRainiig to fax deduction. (Moie����e�ed; however, a surviving
spouse wlro receives a deduction under Section IV may nof receive� I ct n un e o l.)
FILING DATES:
REAL PROPERTY: DURING THE YFAR FOR WHICH THE DEDUCTION IS SOUGHT.
BEOFOREHMARCH(31 OF EqCOR E�,4RN fOR WHICH THE IND V DUAL W SHE S TO OBTqIN'FtiE �EbIdAT�RJ,NN THE TWELVE (12) MONTHS
t4
� I Totalty disabled veteran (or veferan at leasf age 62 with at leasf 1� disebility)�r'S�plv�1{�g�spouse - Not to exceed 512,480
Complete sections I. V antl VI. QC G1.1-12-14) (\�)'`y�-\
� II Partialty service-connected disabled veteran OR wrvivinq spouse - Na����� v
Complete sectbns 11, V and VL QC G1.L12-13) Y AUDITOR
❑ III World War I Veteran - Not to exceed 518,720
Complete sactions IIi, V and VL (IC Gt.t-12-17.4)
❑ N Surviving spouse of World War I Vete2n - Not to exceed 518,720
Complete sections N, V, and VL QC 61.Y12-i6)
Name of applirant (firsl, mitldle, las�
Address (stieet and number, dty, state, andZlP code) County
�.�1. �len e St. 6:bso
Applirant Qdces �foes not ) oan property with another intlividual(s) besides spouse antl/or another veteran.
This applicaUon is made for the purpose of obtaining 5 � yi 9� deduction from the assessed valuafion o( the foliowing described laxabie
tty fw the year 20
�n trict (cily, to vq township) Is the property in questio�: Parcel w Key number �n/� �,/� -7 �q
/�(��� � Real Property ❑ Mobile Home (IC 6-1.1-7) �}-� a"07—� ���XJ�' �0 " d C1
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❑ Appficant vras a membes of the U.S. Artned Forcas for at least 90 days (rrot riecessaNy dumg xar6me�
B. ❑ APP6cant vras honorady dischar9ed.
C. � Appliant is: ❑ TotaDy d�sabled; or
❑ At least age fi2 vrith at I�st 10% disabi6ty
D. � App6ranPs d�saWLry ¢ evidenced by ❑ Certifrate of eli�bi5ry Gam ihe Intliana Departrnent of Vete2ns Affairs:
❑ Pension ceAificate;
❑ Award of campensatlm fram Veterans Administratim or Deparhnerd of Defense; or
❑ Ve,e2ns Adrtrinistration Form 20.5�455 "rau Abatemenf CeAfirate'
E. ❑ The assessed vakiation (at 1009F) d the properry fw wtich Me deduction s c}airtied (maynot exceed 5143, 76� S
F. ❑ AppficaM is ihe siuviving spouse of an aidividual who v.ould have quaGfietl fa the deduGion under ihis sedion when he or she was elive.
(Age d deceased veferen on tlate ddeeN )
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A� Applicant was a member of the U.S. Artned Forces duri� any of its wars.
B. � Applicant was honwably dischar9ed.
C. � Applicant has a seMce conneCed disabiiiry of at least tONo
D. � ApptinnYs disabiGty is evidenced by ❑ Certificate ot elgibiliry fran Ne Indiana Department of Vetuans ARairs;
❑ Pension certifiqte;
� Awartl of compensatbn from Veterans Administra�on or Departrnent of Defense; or
❑ Veterans Adminis[ration Fomi 2(1-5455 "Ta�c Abatement Certificate
E. ❑ Applirant is Me wrviving spouse of an individual who would have quaiified for the deduction under this sectbn when he w she vras alive.
(Age o/ deceased veferan on dafe W deafh )
.
A QApp6rant's a vetaan of Worid War I.
B. QApp6canPs service is evidenced by ❑ Letter 6am Veterars Adrtm�stration a Deparfmenl d Defense; w
❑ Discharge dowments
�. ❑ me ass�ed �an,�mr, (ac ioovc) ot u,e Prov�nv ror wnk+, a� aed�wm �s aar�d (may.�or ��d szos,soo) s
D. Q The pmpesly is ihe appfiraN's pruiapal reside�.
E. QThe appfic2nt wmetl ihe pmpeny (or xas 6uy"u�g it �mder con6ac� for at least me year befoie the date of Ma app&atbn.
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