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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
W1NI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Form 12662 (RB / 4-04)
Prescribed by the Department of Local Govemment Finance
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'aSTRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may 6e checked; however, a sun%iving
spouse who receives a deduction under Section IV may not receive a deduction unde� Section Il.)
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 atleast age 62 wifh atleast 10% disabilityJ or surviving spouse - Not to exceed 512.480
Complete sections I, V and VL QC 6-1.1-12-14)
\�II Partially service-connecied disabled veteran OR surviving spouse - Not to exceed 524,960
� Complete sections II, V and VI. (IC 6-1.1-12-13)
❑ III Wodd War I Veteran - Not to exceed 518,720
Complete sections III, V and VI. QC 6-7.1-12-17.4)
❑ IV Surviving spouse ot Wodd War I Veteren - Not to exceed 578,720
Complete sections N, V, and VI. (IC G7.1•12-16)
Name of applicant ((rst, i/e, last) �
Address (sf2 nd number, c y, state, ZIP code) C
V
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Applicant ( does / does not � own property with another individual(s) besides spouse and/or another veteran.
This application is made for the purpose of obtaining 5 C� � 1� � deduction from the assessed valuatlon of Ne (ollowing described Wuable
property (or the year 20_
Ta�ting District (city, town, township) Is the property in question: ar umber
�eal Property ❑ Mobile Home (IC 6-1.1-7) O ��,
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J. . . .
�� Applicant was a member of fhe U.S. Armed Forces for al leasl 90 days (rwt necessany dunng war G"me).
B. ❑ Applinnt evas hono2bly discharged.
C. 0 Appticant is: ❑ TotaDy disabled; or
❑ At leasf age 62 with al least 10%disability
D. � ApplinnPS dsability is evidenced by. ❑ Certificate of eGgibility from the Indiana Departrneni of Velerans A(fairs;
❑ Pension certifidte;
❑ Award of mmpensation Gom Vete2ns Administration w Departrnent of Defense; or
� Veterans Administration Fortn 20.5455'Tax Abatement Certificate'
E. � The assessed vahialion (at 100%) o( fhe property for which the deduction is daimed (mayrrot exceed 3713,000) 3
F. ❑ Applicant is the surviving spouse of an indrvidual who �wuld have qualified for the deduction under tftis section when he or she was alive.
(Age o/deceased veteran on date ol.death )
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A. ❑ Applicant was a member of the U.S. Artned Forces during any of its wars!
B. � Appiicant was honorably discharged.
C. ❑ Applicant has a service-connected disability oi at leasi 10%
D. � ApplicanPs disabiiity is evidenced by: ertificate o( eligibility from the Indiana Depariment oi Veterans Affairs;
Pension certificale;
❑ Award of wmpensation from Veterans AdminisVation or Department of Defense; or
❑ Veterens Administre6on Form 20-5455'Tax Abatement CeAificate'
E. 0 Applicant is the surv"rving spouse of an individual who would have qualified for the deduction under this section when he or she was alive.
(Age o/deceased veteran on date o/death 1
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A 0 Applipnt is a veteran of Worfd War 1. �
� P,ppGpnYs disabi6ry is evidenced by ❑ Letter Uom Veterans Administration or Departrnent o( Defense; or
❑ Disc3�arge documents -
C. 0 The assessed valuation (at 100%) of fhe property for which the deduction is daimed (may not exceed 5163,000) $
D. ❑ The property is the applicanPS prirxipal residence. , .
E. 0 The applicant ovmed the pmperty (w was buying d under con6ad) for at least one year before the date of Gus apptica6on.
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