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Form Number 12A - Revised 19lI �/�
Prescribed by State Board of Tax Commissioners J ,
•� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABII.ITY q
and Apnlication for Deduction From the %
Assessed Valuation of Taxable Prooer� �
*** pualifications On BacY. *** �/'� _ / `� /,
(Name) �,..�.�,.�,�� %/�'_ /�j.�i o� being duly sworn on oath says
that (s)he is �/ years of age; that (s)he resides at
_._ _�_ _
� �� �'�% ��f1�p� in , County, Zndiana; that (s)he
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 has a service-
connected disability of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
Pension Certificate or '
Award of Compensation or
�_ Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
`" Letter statement of ten percent disability or more from the
Department of the Defense Disability Retirement Board of the
� appropriate branch of the armed forces
exhibited to the County Auditor.
/��'� , �se�
IC 6-1. 1-12-13 and 6-1. 1-12-15 p o 0
/98�-3 .
That this application is made for the purpose of obtaining--6�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�_Z,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER �7lT�qf% ��
r�f
��h�,� a�lition to the above amount of $ deduction applied
9 A
for in this�CO nty, (s)he has or intends to apply for $ deduction
�tiH� 1 L` ��(:Z
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AUDITOR U '
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County, Taxing District.
J� ,-- TL�Cr.�G
(A icant/Guardian)
Subscribed and sworn to before me,
day of �� �A�yi,� , , 19�_
�._�
and disability verified this �
i
—� ,�E �P�d /.!I-�8��
Audito �