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Form Number 12 - Revised 1977
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILITY
and Application for Deduction From the fJ,` �
Assessed Valuation o£ Taxable Property ��"�
_ **• Qualifications on Back x**
STATEi O�'� A w�J'J[LYL COUNTY , SS :
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(Name) n, being duly sworn on oath says
that (s)he is � years of e; that (s)he resides at
in ��
� rq,,�Q��o-(L�County, Indiana; that (s)he
Check One: . `was a nurse
_,�� was a Member of the U.S. Armed Forces
or the'widow of a m r of the U.S. Armed Forces
and who served for ninety (90) da s or more, not necessarily during the
time of war, and has been honorably discharged therefrom and has a total
disability an is entitled to this deduction as evidenced by:
Pension Certifica or � (
�Vward of Compensation or �
eterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of Total Disabliity from the Department.of the
Defense •
Disability Retirement Board or the appropriate branch of the
armed forces
exhibited to the County Auditor. �
�' IC 6-1. 1-12-14 and 6-1. 1-12-15 /��� i1 �QQ
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That this application is made for the purpose of obtaining $�
(not to exceed one thousand dollars) deduction from the assesse valua-
tion of the following described taxable property for the year 19�, to
wit: �
TAXING DI ICT (CITY� TOWN, TOWNSHIP) ��jV�
LEGAL DES�P�I�I O�E�UMBER � Q � �Y ��
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That, in ddition to the above amount of $ deduction applied
l= I�H,�t 2 5 iGE? �
_ £or in this County, (s)he has or intends to apply for $ � d'eduction
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in ;,,�,r n �o �ty, - Taxing District and that
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the total assessed value of all his/her taxable property as shown by the
tax duplicates of all counties in which ey own property is $
. X�.�,� �- � ��
� (Applicant/Guardian)
Subscribed and sworn to before me, and disability verified this •w
� day of ���,(/� , 19�
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