Veterans_KendallFo?m Number 12A - Revised 1977
�� Prescribe�•by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
1 and Application for Deduction From the
�� Assessed Valuation of Taxable Property
' *** ualifications On BacY. ***
STATE OF INDIANA _�� QJ'�1(� COUNTY,
(Name) beina duly
:h (s)he is years of age; that (s)he resides
�
SS:
sworn on oath says
a t �JO �'/ �_Q,(/,.�
in County, Indiana; that (s)he
Check One: was a yember 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 �' e�-�7
con'n�ected disability of ten percent (10 percent) or more ��ji���
entitled to this deduction as evidenced by: c�
Pension Certificate or (��IAY ]Q,j?50
Award of Compensation or
_� Veterans Administration Form 20-5455 "Tax Abatemen Certi icate" or
Letter statement of ten percent disability or mor���e�S
Department of the Defense Disability Retirement Boar�U�i70Rhe
�--, appropriate branch of the armed forces
�exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $��QO•oo
(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 DESCRIPTIO
That, in addition to the above amount of $ O� Q deduction applied
for in this County, (s)he has or ip�e.� ds to apply for $�W� deduction
in County, v Taxing District.
" ���Ud�/L������
/(�pplica /Guar ian)
� Subscribed and sworn to before me, and disability verified this �
r
- day of , 19�. � '�,
IY�/Y� �J ' 1 I I i�,l/�..�— �.
Auditor ��—