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� Form Number 12A - Revised 1985
' Prescribed by State Board of Tax Commissioners
�" VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTE���LIT�
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and Application for Deduction From t1�� � �
^"'' Assessed Valuation of Taxable Property
'•,�` *** Qualificat�ions On BacY. *** NOV 24�19�%
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;TE OF IND ANA I.L(/7-� COUNTY(�''✓� �. d .S
(Name ) ('�G�e.r�f.�. /YT , Gt/n..t,(Z g Y AUDITO� Y
, bein dul sworn on oath sa s
�hat (s)he is _�j years of age; that (s)he resides at %�9 ��
�j�l� in /,� �yi�x- 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 therefrom and has a service-
connected disability of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
-_.
Pension Certificate or
Award of Compensation 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
-��`L appropriate branch of the armed forces
� -'\�.���iibited 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'$�g�
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 i� ,
to wit: �Q •
TAXING DISTRICT //L.�rC.��i�,.�+
LEGAL DESCRIPTION OR KEY NUMBER Z C ��L(�t_�c�
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxinq District.
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X o5 �. o Ol�OJ �% /IJ��G�/
�cant/Guardian) ,
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���� Subscribed and sworn to before me, and disability verified this o�
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:y of �%j%(nr-. �-�i , 19�.
� �,�. �C1-'. h�,�ss
Auditor