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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETEftANS
Stata Fortn 126fi2 (R7 / 6-03)
Prescribed by Ne Department of Local Govemment Finance
iNSTRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving '�
spouse who receives a deduction under Section IV may not receive a deduction under Section ll.)
G DATES:
PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
ILE HOMES (61.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION. g�1
❑ I Totally disabled veteran (or veteran at least age 62 with at leasf f 0% disa iliry) w�u� s� - ot t xceed 56,000
Complete sectlons I, V and VI. (IC 6-7.1-12-14) �
❑ II Partially servica-connected disabled veteran OR surviving spouse - Not to exca�,�,�,o�ol gB03 r�
Comptete seUions II, V and VI. (IC 6-1.1-12-13) `
❑ III Warld War I Veteran - Not to exceed 59,000 �
Compiete secUons ill, V and VI. QC 61.1-12-17.4)
❑ IV Surviving spousa of Wodd War I Veteren - Not to exceed 59,000 GIBSON O���y l.U44T0�
Comolete secUons IV. V. and VI. (IC 6-1.1-72-161
Name of applica fi t, middle, slast f� __�
` - — - ' �— —
Address (shaet number, ciry and sta[e) Zip C
O / o50X�
Applirant ( does I does not ) own property wiih another individual(s) besides spouse andlor anoNer veteren.
This applica4on is made for the purpose of obWining 3__jC�iC�.I�'(Q� deduction from the assessed valuation of the following described taxable
2 f �
pmperty (or the year 20 bd .
Ta�tin sNCt ('city, town rownship) s t property in queslion: Pa I or _ pu r— ��
eal Property ❑ Mobile Home QC 6-1.1-7) � f_ ��p� �j C:J v �'
• . . � .. �' ..• . �'� . .�
� AppGrant was a member of ttie U.S. lvmed Forces for at least 90 days (not necessarily dunng �rar Orrre).
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����,�5h«,��d��. a(� -� a.-�i - �loy -000 • 391 -oa�
. AppGcant is: ❑ Totally disaded; a
❑ At least age 62 with at least 10% disab�lity
D. ❑ Applicanfs disability is evidenced by: ❑ Certificate of Nigibiiiry from the Indiana Department o( Veterans Aftairs;
❑ Pensim cerUfipte;
❑ Avrard of compensation trom Veterans Administra6on or Departrnent of Defense; w
❑ Veterans Administraton Form 20-5455'fax Abatement Certificate"
E. ❑ The assested valuation (at 700%) af the property for whidi Ne deducUon is daimed (may rat exceed 5713,000) S
F. ❑ P,pplicant is ihe wrviving spouse of an individual who wpAd have qualfied for the deduction under this secUOn when he w she was aWe.
(Age o/deceased veteran on date o7death 1
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A. � Applipnt was a member of the U.S. Armed Forces during any o( its wars.
B. ❑ Applipnt was honorably discharged.
C. � Applicant has a senice-connected disabiliry of at least 10%
D. � ApplicanYs disabiliry is evidenced by: ❑ Cenifirate of eiigibility from the Indiana Department of Veterens Af(airs;
❑ Pension certificate;
❑ Award of compensation from Veterans Administratlon or Department of Defense; or
❑ Veterans Adminislralion Fortn 20.5455'Tax Abatement Certificate'
E. CJ Applicant is the surviving spouse of an individual who would have qualified for the deduction un0er this sectlon when he or she was alive.
(Age o/ deceased veteren on date ol deafh )
• . .
A � Apdirant is a veteran of Worfd War I.
7 ApptiranYs disab�ity is evidenced by ❑ Letter from Veterans Administralion w Oepartrnent of Detense; w
q ❑ Dis�harge documents
The assessed valuaaon (at 100�) of the pmperty fwvAiitl� the deduction is daimed (meyrwt exceed 5163,000) S
D. ❑ The pfnperty is the applicanYs prindpal 2sidence.
E. � The applipnt wmed Ne property (or �ras buyirg it urider oon6aC) fw at least one year befae the date ot this appliration.
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