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Form Number 12A - Revised 197!
Prescribed by State Board of Tax Commissioners
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I VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY '
30,3
� and aoolication for Deduction From the
�` Assessed Valuation of Taxable Property
If *** Qualifications on Bac'r. ***
��STATE OF ZNDIANA /;1C.(,(i117�� COUNTY,
` �
' (Name) '�.Q�� ,�'(//V�.t�wc{ , beina duly sworn on oath says
i that (s)he is years of age; that (s)he resides at 7i��y�.
I ( �f , ' ;
' �/3 in County, Indiana; 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 therefro �and has a service-
connected disability of ten percent (10 percent�l„�� ��r��s
entitled to this deduction as evidenced by: r� _�
Pension Certificate or '
Award of Compensation or ^p? �3 I�&)
_� Veterans Administration Form 20-5455 �.x b�tsment�,Certificate" or
Letter statement of ten percent disabiYit�ox3a�g�r�� f o the
Department of the Defense Disability Retix�$�R Ua of the
/ appropriate branch of the armed forces
� \��" /nibited to the County Auditor.
' � / 9 �'� ``�°°e
IC 6-1. 1-12-13 and 6-1. 1•12-15 / a g.L � 3 p O O
/ 7
That this application is made for the purpose of obtaining $-�p�—�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 �oZ ,
to wit: •
TAXING DISTRICT �/�yyt��j�y�, �
LEGAL DESCRIPTION OR KEY NUMBER ��.j� /�j����
That, in addition to the above amount of $ deducti-on-applied
for in this County, (s)he has or intends to apply for $ deduction
in County, � Taxinq District.
X
(Applicant/Guar ian)
��Subscribed and sworn to before me,
;.:Y of �(,N� , 19Cf�.
a-
and disability verified this � �
i
✓� /� ,
Auditor
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