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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS�
State Pwm 12662 (R6 / 10.01)
Presmbetl Cy U�e Department o( Local Govemment Finance
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INSTRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduction unde� Section ll.)
JG DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (&1.1-7): BETWEEN JANUARY 15 AND MARCH 31 OF THE YEAR THE DEDUCTION IS TO BE EFFECTIVE.
� I Totally disabled veteran (or veteran atleast age 62 with at least 10% disability) or surv'rving spouse - Not to exceed 56,000
Complete sections I, V and VI. (IC 6-7.1-12-14)
❑ II Partiaily service-conneded disa6led veteran OR surviving spouse - Not to exceed 512,000
Complete sections II, V and VI. (IC 6-7.1-12-13)
❑ III World War 1 Veteran - Not to exceed 59,000
Compiete sections III, V and VI. (IC 6-1.1-12-17.4)
❑ N Surviving spouse of World War I Veteran - Not to exceed 59,000
Comolete seGions N. V. and VI. fIC 6-7.1-12-i61
Name of a p' t(first, m' dle, las . � � .
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Address (street and number ci and stat i Zip code Counry
Appli�ant ( dces / does not � own property vrith another individual(s) besides spouse andlor another veteren.
This application is made.for ihe purpose of obtaining 3 dedudion 6om the assessed valuaGon desaibed lazable
property, for Ne year 20_ � • �
Taxing District (city, town, township) - Is the prqperty in queslion: arcel or Key number
�' eal Property ❑ Mobile Home (tC 6-1 ) _ O� � — Q�
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] ApPGcanl was a member of the U.S. Am�ed Forces for at least 90 days (not neoessan7y du ' wa ' ). �� —(� p
B. � AppGcarrt was hofrorably discharged.
C. ❑ Apptipnt is: ❑ TotaOy disabled; or
❑ At least age 62 with at least 10%disabildy
D. ❑ ApplianYs disabArty's evidenoed by ❑ Certficate of etigibility 6om the Indiana Department of Veterens Aftairs;
❑ Pension certifiwte;
❑ Award af campensalion 6om Veterans AdminisUation or Departrnent of De(ense; or
0 Veterens Adrtdnstration Form 20.5455'fax Abatement Certifipte'
E. ❑ The assessed vaNafion (at 100°h) of the property for whitli the deducation is daimed (may rat exceed 854,OO�j S
F. � Appli�ard's the wrv"Nirg spouse ot an uMividuat who xrould have qualified for Ihe dedudan under this seUion when he or she was alive. �
(Age o/deceased veteran m date oldeath 1
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A. ❑ 9pplipnt was a member of the U.S. Artned Forces during any of iLS wars. �
B. �Applinnt was honorabty discharged.
C. C�Applicant has a serviceconnected disability of at least 70°h
D. � P.pplicanfs disability is evidenced by: ❑ Certificate of eligibility 6om the IrWiana Departrnent of Veterans Affairs;
❑ P sion certificate;
Award of compensation from Veterans AdminisVation or Department of Defense; or
❑ Veterans Administration Fortn 20.5455'Tax Abatement Certificate'
E. ❑ Applipnt is the surviving spouse�of an individual who would have qualified for the deduction under this secGon when he or she was alive.
(Age o/deceased veteranon date oI death )
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A❑ Appbcant is a veteran of World War I.
App6prrt's d�sabady is eviden�cd by ❑ Let[er fiom Veterans AdminisVation w Departrnent of Defense; or
� ❑ Discharge dowments
C. ❑ The assessed valuation (at 100°,G) of the property tor which the deduntion is dauned (may rat exoeedY78,OOQ) S �
D. ❑ The propefty is the applicanl's prindpal residence.
E. 0 The appGpnt owned the pmperry (or was buyirg d under mMiacQ fir at least one year before the date of this applica6on. _
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