Veterans_Whitee� .."'". APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
� WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fwm 12662 (R71 /10-0H)
�u � Prewibad Oy the DeparUneM d Lo�l Gwamment Finanoe
�STRUCTIONS: Please check appropriate box(es) pertainim� to fax deduc6on. (More than one box may be checked,� howeve�, a surviving
spouse wFro receives a deduc6on under Seclion IV may not receive a deduction under Sec6on Il.)
FILING DATES:
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT.
MOBILE HOMES (IC Et.1-7) OR MANUFACTURED HOMES NOTASSESSED AS REAL PROPERTY: DURING THE TWELVE (12) MONTHS
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTION.
❑ I To�alty disaded vete2n (or veteian af leasf ege 62 with at least f 0Ye dise6ility) or surviving spouse - Not to ezceed $12.480
Complete sections I, V and VI. (IC 6-1.Y12-14)
II Partally servicetonnected disaded veteran OR surv'rving spouse - Nol to exceed 524,960
Camplete sections II, V and VI. QC G1.�-12-13)
❑ 111 World War I Veteran - Not to exceed 518.720
Complete secfions III, V and VI. (IC 57.1-12-17.4)
❑ N Surviving spouse of World War I Veteran - Not lo exceetl 518.720
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Complete sections N, V, and VI. (IC 61.1-12-16) �l ' �"' `-�
Name of applicant (6rst, " le, las�
Address(streetandnumber, " sfat andZlPcode County
Applirant Qdces Qlces not ) own property with another irWividual(s) besides spouse antl/or another veteran.
Ttiis application is made for fhe purpcue of obtaining Say��/ deduction from the assessed �raluation of the fdbvring described taxable
property fa the year 20�_.
Tasin istrict (city, town, fownship) Is the rty in question: Parcel or Key number (�
eal Pmperty ❑ Mobiie Hame (iC 6-1.1-7) 6� � d
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❑�+aW� �ras a mrmber or the u.s. rvmed Foroas for at �Pas� 90 days (na nefassenN dum�g wsra.na�
B. ❑ App6cant vras honorady discharged.
C. Q AppfraM's: ❑ To�y disabled: or
❑ At least age 62 with at I�st 10% disahifity
D. ❑ App&2nYs dsabdry 6 evidence� by ❑ Certificate of d'gibi�ty from ihe Ind"ana Departrnent of Vate2ns ARairs;
❑ Pension certificak:
❑ Award of arnpensatim fran Veterans Administratim or DeparMent of Defense; w
❑ Veterans Administration Form 20.5455 Taz Abatsnrnt Certifipte'
E. ❑ The assessed �aAiation (at 100%) of the property �or wli� the detluctlon "s claimed (may rrot exceed 5143, 76� S
F. ❑ Applicard is ihe surviving spouse of an uWividual wta would have qualified fw the deduction untler iha secfion when he or she was alive.
(Age ddeceased osteran on dale d death )
. . .
A Q Applicani was a member of Ihe U.S. Artned Forces during any of its vrars.
B. � Applicant was honorably dischar9ed.
C. ❑ Applirant has a seMce conneded disabiliry of at st 10°�
D. ❑ AppGcant's disabiliry is eviderred by. rtifxa[e of eligibiliry (rom the 1`Miana Depariment ot Veterans ARairs;
❑ Pension rertifirate;
❑ Award of compensa6on fran Veterans Administra6on w Departrnent�of Defense; w
❑ Veterans Adminirnatian Form 20-5455 Tax Abatement Certificate'
E. ❑ Appiicant is the wrviving spouse ot an individual who would have qualified for the deduction under this seGion when he w she was alive.
(Age of deceated vefe�an rn date ol deafh )
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A QApp6cant is a vetaan o( Workl War I.
B. ❑App6caM's seni[e is evidencetl by ❑ Letter Gom Veterans Adrtmia4ation or Depariment (A Defensa; w
❑ Dsci�arge do�ments
�. ❑ The assessed van,alion (at too^c) ot u,e properry ror whia, me tledu�tim is aairned (may not exceed 82o6,soo� S
D. Q The property is the appfrant's pr'v�al msidence.
E. ❑The app5mnt wmed ihe pmpelty (or xas 6uy'mg it �r arNac� for at least ane year be`ora ihe date of tt� app5cafiwt
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