Veterans_Mattox�Form Number 12 - Revised 19l7
�Prescribed by S"t'ate Board of Tax Commissioners
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VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILZTY
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and Application for Deduction From the
Assessed Valuation of Taxable Property ��tL
*** Qu lifications on Back *** � �„�p
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STATE OF INDZ NA COUNTY, SS: ila �
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(Name) , being duly swor on oath says
that (s)he is years of age; that (s)he resides at
in County, Indiana; that (s)he
Check One: was a nurse �
� Member of the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
and who served for ninety (90) days or more, not necessarily during the
time of war, and has been honorably discharged therefrom and has a total
disability and is entitled to this deduction as evidenced by:
Pension Certificate or aco-���o�-`�03-°°'•�� °��
Award of Compensation_or
eterans Ad¢iinistration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of Total Disabliity from the Department of the
Defense
_ Disability Retirement Board or the appropriate branch of the
armed forces
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exhibited to the County Auditor.
IC 6-1. 1-12-14 and 6-1. 1-12-15 ���G , yo 0 0
That this application is made for the purpose of obtaining $ O o O
(not to exceed one thousand dollars) deduct'on from the assessed valua-
tion of the following describe�taxable p pqf�� the year 19_, to
w i t : � .�C� .
TAXING DISTRICT (CITY� TOWN, TOWNSFI� /
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LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $
deductio`i5 applied
for in this County, (s)he has or intends to apply for $ deduction ,
in County, Taxing District and that -
the total assessed value of all his/her taxable property as shown by the
tax duplicates of all counties in"which they own property is $
X �.
� (Applicant/Guardian) '�
Subscribed nd sworn to before me, and disability verified this
,3 day of , 19 p y.
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Audi