Veterans_Pickersgill/ '�°'A, APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, �
;"s� -. :': V111NI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
•�� �� State Porm 12662 (RB / 4-04) .
Prescribed by the Department of Local Government Finance �} a a�3
!+��STRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may e checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduction unde� Section ll.)
_.NG DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION.
❑ I Totally disabled veteran (or veteran at leasf age 62 with at least f0% disabilityJ or surviving spouse - Not to exceed 512,480
Complete sections I, V and VI. (IC &1.1-12-14)
�II Partialty serviceconnected disabled veteren OR surviving spouse - Not to exceed 524,960
Complete sections II, V and VI. (IC &7.1-12-13)
❑ III World War I Veteran - Not to exceed $18,720
Complete sections III, V and VI. (IC 6•1.1-12-17.4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 518,720
Complete sedions N, V, and VI. (IC Gi.t-12-16)
Name of applican first, middle, last)
Address street and numbe� , state, ZIP code) County —�
Applipnt ( does / does not ) own property with another individual(s) besides spouse and/or another veleren.
This application is made for the purpose of obtaining S�y 9�n � deduction from the assessed valuatlon of ihe following described taxable
property (or the year 20_
Taxin strict (city, town, township) Is the property in question: Parcel or Key number
j�A_r�,Cp,�ip.`_ eal Property ❑ Mobile Home (IC 6-1.1-7) o � q- o a� 9 i-�
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•� AppGcant was a member of fhe U.S. Artned Forces for at least 90 days (not necessarily dunng war fime).
B. ❑ Applipnt was trono2by discharged.
C. ❑ Applicant is: ❑ Totally disabled; or
❑ At least age 62 vriih at least 70% disability
D. 0 ApqipnPs dsab0ity is evidenced by. ❑ Certifipte of eligibiliry trom the Indiana Departrnent of Veterens Aftairs;
� ❑ Pension certfipte;
❑ Award of compensation trom Veterans Administration a Department of Defense; or
❑ Veterans Administradon Form 20.5455'Tax Abatement Certificate'
E. � The assessed valuation (at t00Yo) of the property for which ihe deducfion is davned (may not exceed $713,000) 5
F. � Applicant is the survrving spouse of an individuai who vrould have qualified for the deducfion under Utis section when he a she was aGve.
(Age of deceased vete2n on date of death )
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A.� Applicant was a member of the U.S. Armed Forces during any of its wars.
B. Applicant was honorably discharged.
C. � Applicant has a service-connected disability of at least 10%
D. 0 ApplicanCs disability is evidenced by: � Certificate of eligibiliry from ihe Indiana Department of Veterens Aftairs;
❑ Pension certifiwte;
❑ Award of wmpensaGon from Veterans Administration or Department of Defense; or
[� Veterans Administra6on Form 20-5455'Tax Abatement Certificate'
E. ❑ Applicant is the surv'rving spouse of an individual who would have qualified for the deduction under this secUon when he or she was alive.
(Age ol deceased veteran on date ol death )
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A � AppGpnt is a veteran ot Wor1d War I.
� AppfipnYs disabiGry is evidenced by: ❑ Letter from Veterens Administrafirn or Departrnent o� Defense; a
❑ Disdiarge documenls -
C. � The assessed valuaGon (at 100°/,) ot the property for which the deduction is Gaimed (maynot exceed 5763,000) $
D. � The property is the applipnCs prindpal residence.
E. ❑ The applicant owned the property (a was buying it under con6act) for at leasi one year befwe the date ot Uils applicafion. .
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