Veterans_LagneauForm Number 12A - Revised 197! —�
Prescribed by State Board of Tax Commissioners �
_- VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY �—
and Aoplication for Deduction From the
' Assessed Valuation of Taxable Pronerty
�d *** Qualifications On Back ***
STATE OF INDIANA ���-yLJ COUNTY, �
(Name)`J� �.�. , being duly sworn on oath says
. \
that (s)he is �� years age; that (s)he resides at 7��% 6�j[�-Z �
� in ���n� County, Indiana; that (s)he`2 `�-�
Check One• ✓ was a Member of the U S Armed Forces during any of
� its wars
- or the wido mber of the U.S. Armed Forces
who served during an f its wars
and who has en honorably discharged therefrom and has a service-
connected dis�ity of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
al�-i a-��-yoa-ool �535-��8
1
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Pension Certificate or '
Award of Compensation or
Veterans Administration Form 20-5455 "Tax A atement Certificate" or
Letter statement of ten percent disability or more from the
Department of the Defense Disability Retirement Board of the
i appropriate branch of the armed forces
�
�.; exhibited to the County Auditor. / p�6 poo
IC 6-1. 1-12-13 and 6-1. 1-12-15 / �
/i8y 3oa
That this application is 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 DESCRIPTIO
That, in addition to the above amount of $
�SO O ^ �,_�SO
deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
plicant/Gu�fdian)
Subscribed and sworn to before me, and �sa�i_ i y��ffled this o�
���• !� y..ri —
day of ��� , 19 �P/. /1
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