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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Form 12662 (R6/10.01)
P�eunbed by Ihe Department o1 Local Govemmem Finance
�' TRUCTIONS: Please check appropriate boz(es) pertaining to lax deduction. (Mo�e than one box may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduction unde� Se ' n .)
' �.G DATES: �r �{
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DE�y�:TIj�N TO��
MOBILE HOMES (6-1.1-7): BENVEEN JANUARY 15 APlD MARCH 31 OF TFiE YEAR THE�Ebu�n E'�FECTIVE.
❑ I Totalty disabled veteren (or veteran at feast age 62 with at least 10% disability) or survivin spAu� -AM�� exceed 56,000
Complete sections I, V and VL pC 6-t.t-12-14) DE� � cw
❑ II Partialty service-conneGed disabled veteran OR surv'rving spouse
Complete sedions II, V and VI. (IC 6-1.1-12-13)
❑ III World War I Veteran - Not lo exceed 59,000
Complete sedions III, V and VI. (IC 6-1.1-12-77.4)
❑ N Surviving spouse of World War I Veteran - Not to exceed 59,000
c.,�,,,,a�a�e�„o�ivv�„n�n nc�>>_�z�ei
Not to exceedS12,000
�t,- ^.�J�.- :UDITOR
�,;,•;nn� �'�. '
Namep{ap ' nt (first, middle, las� rs __� 4 ,_ O_ L
Address (st2et and number, city and state) � Zip code Co
5 o r� .�.�.
Applicant ( dces I does not � own property with another individual(s) besides spouse andlor anolher veteran.
This appliwtion is made for lhe�purpose of obWining $`-.� . U deduGion from the assessed vatuaGon of the folowing desuibed taxable
property. for the year 20_ � . � - r-
T i DistriG (dty, town, township) Is the property in question: Parcel or num
I Property ❑ Mobile Home (tC 6-7.1-7) ��- •
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��] Appticant was a member of the U.S. Artred Forces for at least 90 days (nof necessan'y dunng war time).
B. ❑ Appti�ant was honoreby discharged. O� �� Q� 3lp y'�
C. ❑ Apptipnt is: ❑ TofaDy disabled; or ` �
❑ At teast age 62 wRh at least 70°h disability a(�-I a-� 8-� 0 3- o a. 3eo y+0o1$
D. ❑ AppliranYs disabday's eviden[ed by. ❑ Certifipte of eligibility 6om fhe Indiana DepaNrent of Veterans Affairs;
❑ Pensbn certficate; .
❑ Award of mmpensation from Vete2ns Administration or Departrnent of Defense; or
❑ Veterans Adminatration Form 20.5M155 Tax Abatement Certifipte'
E. � TTe assessed valuation (at 700 h) of the property for whidi the deducation is dacr�ed (may raf exceed S54,OOQj $
F. ❑ Apptirant's ihe wrviviiy spouse of an individual who would have qualified fw the dedueYion under this seUbn when he w she was alive. �
(Age of deceased veteran rn date o/deafh )
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A O Appliqnt was a member of the U.S. Artned Forces during any of its wars.
B. � Applinnt was honorably discharged.
C. ❑ Applicant has a service-connected disability of at least 10°h
D. ❑ ApplicanYS disabiliry is evidenced by: �ECttifiqte of eligibility from ihe Indiana Departrnent of Veterans Affairs;
❑ Pension certificate; � -
❑ Award of compensalion 6om Veterans Administra5on or Departrnent of Defense; or ,
� ❑ Veterans Administration Fortn 20.5455'Tax Abatement Certifipte'
E. ❑ Appliqnt is the surviving spouse�of an individual who would have qualified for the deduction under this sec6on when he or she was alive.
(Age o/deceased veferan�on date ol death )
• . .
,�❑ AppGraM is a veffi2n of WoM War L �
❑ App&anYs d'aabildy'a evidenced by ❑ Letter from Veterens AdminisVation or DepaNrent of Defense; or
❑ D'ischarge documents
C. ❑ The assessed vaWation (at 700°,6) of ihe properry tor whiGi Ne deducation is da"vned (may rat exoeed 579,00� $
D. � The propefty is the apptirar8s prindpal residence.
E. O The app&artl ovmed the property (a was biry'vg d ur�es oon6acn for at leasl one year before the date of ihis application.
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