Veterans_Hasselbrink•�" APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, ��
� WWI VETERANS AND SURVtViNG SPOUSES OF CERTAIN VETERANS
y � State Fortn 12662 (R915-OB) �
,a.
Presaibed by Ne Departmem of Local Govemment Rnanw
�RUCTIONS: 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 11.)
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-t.t•7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION.
�Totally disabled veteren (or veteran at least age 62 vnfh ar least 70% disabiliryJ or surviving spouse - Not to exceed 512,48G
Complete sections I, V and VI. QC 6-1.1-12-14)
�I Panially service-connected disabied veteran OR surviving spouse - Not to ezceed 524,960
Complete seUions 11, V and VI. (IC 6-1.7-12-13)
World War I Veteran - Not to exceed 578.720 1� � 1�
Complete seciions tll, V and VL QC 61.7-12-17.4) �-
❑ IV Surviving spouse of World War I Veteran - Noi to exceed 518.720
Complete sections IV, V, and VI. (IC 6-1.7-12-76)
Name applicant (first �ddle, last) Date of binh (month, day, yea�
Address (streef a� number, cify, sta e. ZI code) Coun
Appliwnt ( dces I dces not ) own property with another individual(s) besides spouse and/or anoNer veteran.
This applicalion is made for Ihe purpose ot obtaining $ 3%'! �� deducUon from ihe assessed valualion ot the following described taxable
property for the year 20_
T- istrict (�, fownship) Is the property in queslion: Parcel or Key number
� eal Property ❑ Mobile Home QC 6-7.1-7) � _ S� e�00 �('O
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A � App&ant �ras a r�rember of tl�e U.S. lvmed Fwces fa a[ least 90 days (rrot necessarny durirg war hme� �
B. � App6pnl Nas horwrably d�,d�arged.
C. ❑ AppGrant is: � Totally disaded; a ..
❑ Al leasc age 62 w�h a[ leasl 10% disability .
D. Q ApplicanCs disabifRy is evidenced 6y �te d e6gbdity Gom tlie Indiana Departrnent of Veterans Affairs;
Pens+m certfKate;
❑ Award of canpensalion 6om Veterans Admmistration or DepaNrrent of Defense; a '
❑ Veterans AdminisbaUOn Fortn 20.5455 Tax Abatemerrt CerUfqte'
E �� The assessed valuation (at 100Y,) af the properry for which ihe deduUim is daimed (may rat exceed 5173,000) E
F. 0 Appficant is tlie wrrimring spouse of an irdividual wtw would have qualified fa the deduction under this section when he or she �ras alive.
(Age oI deceased veteran on date W deatlr )
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A � Appiinnt was a member of ihe U.S. Armed Fwces during any of its wars. �
B. � Applinnt was horwrabty discharged.
C. � Appliqnt has a service�connected disabiliry o( at least 10%
D. � ApplicanYs disability is evidenced by ertificate of eligibiliry from the Indiana Departrnent of Veterans ARairs;
Pension certificate;
� Award of compensalion from Veterans Adminislretion or Department of Defense; or
❑ Veterans Adminislration Fortn 245455'Tax Abatement Certificate'
E. ❑ Applicant is the surviving spouse of an indiviAiial whn wrnilA havo qualified fw Ne deduclion under this seclion when he or she was alive.
(Age o/ deceased veteran on date o7 death )
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�� ApplicaM is a veteran of World War I.
J AppPKarrt's disabBiry is evider�ced by ❑ Letter fran veterans AdrtunistraUon or Departrnent of Defense: or
❑ Disdurge dowmenfs
C. ❑ The assessed valuatiwi (at 100%) of ihe properry for vfirich ihe deducUOn is daimed (may not exceed S 763,000) 3
D. O The property is the appGrarrt's prv�cipal r�dence.
E. � The appfxarrt ovmed the prope�ry (or was buying if under cartract) fw at leasi one year before ihe date of this appiication.
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