Veterans_Gaston\
� ���orm Number 12A - Revised 19rr _ ' �i�iD
1:� ''•P,�i�escribed by State Board of Tax Commissioners �' (ob
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY�-3
and Aoplication for Deduction From the
�� Assessed Valuation of Taxable Prooerty
**• Qualifications On BacY ***
STATE OF INDIANA �LQ.1Qj�� COU�TY, S5:
� ,� 1�
(Name) ��� I I..l�\ ,�n�[V� � , being duly sworn on oath says
that (s)he is years of age; that (s)he resides at aa9c�� �Pr,�, o
in County, Zndiana; that (s)he
Check One: was a Member of the U.S. Armed Forces during any of
its wars
�r 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 20-5455 "Tax Abatement Ceztificate" or
Letter stateme� of ten percent disability or more from the
Departmen�o �he De�se Disability Retirement Board of the
appropria��e �`hz.a,�,[rt_� he armed forces
� t
_exhibited to the Co.u��y yy,�d��,Lor.
1 U
��IC 6-1. 1-12-13 and 6-1. 1-12-15
' �`�`-`� �
That this applica��OiT�`as made for the purpose of obtaining $
(not to exceed two 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 ���p� Y��Q��` �nO
That, in addition to the above amount of $�'�(�� deduction apolied
for in this County, (s)he has or intends to apply for $y� deduction
in �1 �
�m County, Taxing District.
t
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(Applicant/Guardian)
.� Subscribed and sworn to before me, and disability verified this � �
day of , 1�. �?
C�2rn �0 1/Yf l,r.c_.�
, Auditor � �