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Form Number 12 - Revised 1977
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILZTY
and Application for Deduction From the
Assessed Valuation of Taxable Property // Q'
r *** Qualifications on Back *** G� Q'�
l /
STATE OF ZNDIANA �/��{J COUNTY, SSi
(Name) , being duly sworn n.oath says
that (s)he ' ge; that (s)he resides at /
�.� years of
in County, Indiana; that (s)he
�J
Check One: was a nurse �
� was a Member of the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
and who served for ninety (90) days or more, not necessarily during the
time of war, and has been honorably discharged therefrom and has a total
disability 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 Total Disabliity from the Department of the
Defense
Disability Retirement Board or the appropriate branch of the
armed forces
exh;�� �ed�o�e�unty Auditor. ///� ������,(� � __
` �.� / -..,�„•
IC 6-1. 1-12-14 and 6-1. 1-12-15
Tha�t�(�th}s jCp(�plication is made for the purpose of obtaining $ G'UQ ,
(not to exceed one thousand dollars) deduction from the assessed valua-
tion�of�the following described taxable proper y for the year 19_, to
W`i t=: � �0 4.�,,,�au� a. �"1 .
TAXI.N�GIIII�STRICT�(�CITY, TOWN, TOWNSHI,P�) [p
� '�`� % � / „ / L ! . � „_ . ,...
LEGAL DESCRIPTION OR KEY NUMBER�
.� ti .
That, in addition to the above�l�mount of $ t� deduction applied
�- for in t is County, (s)he has or intends to apply for $ deduction
�
in County,
Taxing District and that
the total assessed value of all his/her taxable property as shown by the
�- �i
�.
tax duplicates of all counties in which they own property is S �
�2�,�.,,� i,rJ u/��
� (Applicanf/Guardi ) �'
Subscribed and sworn to before me, and disability verified this ,
3 Q d a y o f , 19 (J [� �•` � 0� �i/�c.�!/
,Auditor