Veterans_DorrisForm• Number 12A - Revised 1985 ��
�.Pre'scribed by State Board of Tax Commissioners
_ VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISAB����-,�-
� and Application for Deduction From the
Assess d Valuation of Taxable Property
• Qualifications On Bacy *** JUN 3 0 199g -
STATE OF INDIANA COliNTY, SS � �,/�
GlBSOI� COU ��r • •.0 Tno
(Name) —-� being duly sworn on oa�h�''says
� at (s)he is years of age that (s)he resides at lp Q��•��I�
( .
in County, Zndiana; that (s)he
Check One: t/ 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 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
�/ Award of Compensation or
Veterans Administration Form 20-Sf355 "Tax Abatement Certificate" or
Letter statement of ten percen��disability or more from the
� Department of the Defense Disability Retirement Board of the
� appropriate branch of the armed forces
exhibited to the County Aua�tor. a�-�� �o?-1e� -003. i as-oa8
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $ QoQ•�
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 //,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
�
That, in addition to the above amount of $C�_ deduction applied
for i this County, (s)he has or i
in County,
s to apply for $��0 deduction
Subscribed and sworn to before me,
day of , 19�•
\Fj��4)111:Q[I l� ULLGGp1633 j �
�� ��
and disability verified this� O�
� ��) �
Auditor