Veterans_ReadyForm Number 12A � Revised 1985 '' � ��� " U`''� I ,�
n, P`nescribe-3 by State Board of Tax Commissioners O
� -�
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
�
and Application for Deduction From the
Assessed Valuation of Taxable Property
'** Qualificat'ions on BacY, *�'
STATE OF INDIANA ����� Yr * COUNTY, SS:
(Name) �+�� � O� , being duly sworn on oath says
�h
��h/a�t (a)he is 5� years of age; that (a)he resides at
�ZI/a'1 OfiY1i in County, Indiana;�°�3t s) e��
Check One: � was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S. Armed Forces
who served during any of its wars
and who has been honorably discharged therefrom and ha��s�r�e�
connected disability of ten percent (10 percent) or mo e�n ,6i.�
entitled to this deduction as evidenced by:
ruY o s 7sys
Pension Certificate or
�/ Award of Compensation or (/�'� �
Veterans Administration Form 20-5455 "Tax Aba �-;',eFnenGtiGer�t: -&i�e ' or
Letter statement of ten percent disability of°moY:e���ff!oinTYt9i�e�TO�
�epartment o£ the Defense Disability Retirement Board of the
appropriate branch of the armed forces
- exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $�Q,
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property
to wit:
TAXING DZSTRICT
LEGAL DESCRIPTION OR KEY NUMHE
ye
���
That, in addition to the above amount of $� deduction applied
for in this County, (s)he has or intends to apply for S� deduction
in ��py�q County, �nj �,]—j�„� Taxing District.
X �.�.&..D �� ���
(Applican /Guardian)
�, Subscribed and sworn to before me, and disability verified this _
day of , 19�.
uditor
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