Veterans_DoveForm Number 12 - Revised 1977
�rescribed by State Board of Tax Commissioners
�y
\
�,
�
�
��
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILITY
and Application for Deduction From the � L� /
Assessed Valuation of Taxable Property
- *** Qualifications on Back ***
STATE OF ZNDIANA '�� COUNTY, ��
(Name) ,�i�i�i� ��/T,�'�L , being duly swor/n �on oath says
that (s)he is �3 years of age; that (s)he resides at /
in �ivG��� County, Indiana; that (s)he
Check One: was a nurse
Jwas a Member of the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
and who served for ninety (90) days oz more, not necessarily during the
time of war, and has been honorably discharged therefrom and has a total
disability and is entitled to this deduction as evidenced by:
Pension Certificate or aC� -► a-08 - 3or-��-�Ra -�ag
Award of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of Total Disabliity from the Department of the
Defense
_ Disability Retirement Board or the appropriate branch of the
armed forces
exhibited to the County Auditor.
IC 6-1. 1-12-14 and 6-1. 1-12-15 pp� ��OO�
That this application is made for the purpose of obtaining' $��
(not to exceed one thousand dollars) deduction from the assessed valua-
tion of the following described taxable property for the year 19�L to
wit: . �
TAXING DISTRICT (CITY, TOWN� TOWNSH�) ��
LEGAL DESCRIPTZON OR KEY NUMBER ___�/�GG-�C.- ��-2
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in , Taxing Distzict and that
the total e of all his/her taxable property as shown by the
tax duplicates�G�fl�l��bounties in which they own property is $
� X ' iCk%U i�, �
U �
���. (Appli nt/Guardian)
R�o�soR ..
Subscribed and sworn to before me, and disability verified this '
(D day of �%%('�� , 19 �L
Auditor