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�� �Form Numher 12 - ReviBed 1985 • • -
Prescribed by State Board of Tax Commissioners .
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABI'yL�ZTY '
� and Application for Deduction From the ��j �,�� �
Assessed Valuation of Taxable Property
�*• Qualifications on Back *** ���7'��9�t
STATE OF INDIANA �� COUNTY, SS:/,j.� �. �y s
wni 1,�p,'�-
(NZme? —(�-(� �(�/\ being duly Sworn�o��T�ath says
d� ��l...K O� e w._ O I- I�'L� �
that (s)he is �� years of age; that (s)he resides at S
P� — in ,�L]� County, Indiana; that (s)he
Cl:eck One: was a nurse
was a Member of the U.S. Armed Forces
� or the widow of a aember 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 -
Awar3 of Compensation or �
Vetera;is Adminis_r�tion Form 20-5455 "Tax Abatement Certificate" or
L�tter statemant of Total Disabliity from the Departmen� of t:�e
� _ ,D�fense
Disability Retiremen� Board or the appropriate branch of the
, armed forces
exhibited to the County auditor.
IC 6-1. 1-17-14 and 6-1. 1-_2-15
That ti�is application is'made for the purpose of obtaining $�i��1`J
(net to exceed two .*.housand doilars) deductior: from the assessed valua-
tion of t!xe folloving described taxable prooerty for the year 19_, to
wit: • -�{--
TAXINi= DISTRICT �CZTY� TOWN� TOWNSHIP) a y-� _ /
LEGA_i, DESCRIPTION ')R KEY NUi�BER
That, in addition to the above amount of S deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxing District and that
the to*..al assessed valu� of all his/her taxable property as shown by the
tax duplicates of all counties in which they own property is S
: X il'r'}'�' -" ' «�%7 ,Y�-._ .
(Applicant/Guardian) �'
Subscribec and sworn to before me, and disability verified this �
�5iay of ' 19�. � ,. Q � � c .
Audit r