Veterans_Walker' F� N••mber 12A - Revised 1985
orm L • /�
Prescribed by State Board of Tax Commissioners
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 �y A)U.)L"/�1 COUNTY, SS:
,(�/� NOV 10 1999
(Name) �,('yy� ,. �oSI��.0 , being duly'�sworn on ath says
�hat (s)he is � years of age; that (s)he resid, ''.
G`�i SC: �,..,��n i n i v�
�Q n/1 in ���\�`✓�/`' ` County, Indiana: that (s)he
v
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: i�
Pension Certificate 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.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $'7(J(JV
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�, �
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $� deduction applied
for in this County, (s)he has or intends to apply for $��b deduction
in _��/V � County, �'�� Taxing Dist ict.
X�
: ' u ian)
Subscribed and sworn to before me, and disability verified this L
day of � �S>j— , 19�
� �
Auditor
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