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.�" " APPUCATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
r�" WVYI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERA
S S��F°^^'2�z�9'�� DEC 2 S 2009
Prescribed by the Departmem W Loral Govemment Fnance
�RUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be che�1�ed; hoy�reyer, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Sect�r9rf4kTa �'� ��
FILING DATES: UNTY AUDITOR
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE17 OF THE YEAR THE DEDUCTION IS l��l�
MOBILE HOMES (6-7.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISFIES TO
OBTAIN THE DEDUCTION. •
� I Totally disabled veteran (or ve�eran a� leasf age 62 viith atleast 70% disabiliry) or surdving spouse - Not to exceed 512.48G
Complete sections 1. V and VI. (IC 6-7.7-12-74) �, ' '/
❑ II Partially service-connected disabled veteran OR surviving spouse - Not ro exceed 524,960 �/' rG�
Complete sections I�, V and VI. (IC 6-1.7-72-73) l
�J III World War I Veteran - Not to ezceed 578.720 (
Complele sections III, V and VI. QC 6-1.7-72-17.4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 578,720
Complete secuons IV, V, and VI. (IC 6-7.1-12•76)
Name of appliwnt (�rst, middle, last)
E T s I� r
Address (street and number, cify, state, ZIP code) CounTy/� �_
.SB �� F�G vE. C E%ON D l� BSO
Appliwnt ( does I dces not ) own property with another individual(s) besides spouse arM/or another veteran.
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This application is made tor the purpose o( obtaining $ �,� '�f��. � deduction from the assessed valuation of the follonving described taxable
property forthe year20_
Ta�ting Distrid (cify, town, township) Is the property in question: Parcel or Key num6er
� Real Property ❑ Mobile Home (IC 61.1-7) a -i� �a3��.a90 -�
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rt � App6cant vras a member ot tlie U.S. Armed Forces ta at least 90 days (rrot necessaNy dunrg war �ne}
B. �AppStant �ras honaady disdiarged.
C.,� �nrri is: .� TotaDy disaded; a ..
� ❑ At {east age 62 witli at least 10% disabtlily
D. �AppficanYs disabi(rty is evidenced by. � Cettificate d eGgibBitylrom tlm Ind'ena Departrnen[ of Veterans Affairs;
,� Pensim celtifuate;
� Avrard of cwnpensafion hom Veterans Admmistralion or DepaMient of Deferrse: or '
❑ Veterarrs Admirristra�on Form 20.5455 "Tax Aba[emerrt Celtifinte'
E. ❑. The assessed valuation (at 100%) W ihe property for wtiich ihe deducUm is dair�d (may not exceed $773,000) $
F. � Applinnt is tlie surv"rvmg spouse of an individual who would have qualfied for the deducbon under this secUOn when he w she was alive.
(Age o/deceased veferan on dateWdeaU� )
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A � Applicant was a member of the U.S. Armed Fwces during any of its wars.
B. ❑ Appliwnt was honorably discharged.
C. � Applicant has a servicetonneded disabiliry of at least 10%
D. � Applicanfs disabiliry is evidenced by: ❑ CeRificate of eligibility from the Indiana Departrnent of Veterans Aftairs:
❑ Pension ceRifiwte;
❑ Award of compensation from Vete2ns AdminisVation or Departrnent of Defense; or
❑ Vete2ns AdministraUon Form 20-5455'Tax Abatemwt Certificate'
E. ❑ Applicant is the surviving spouse of an indivirf��al whn wrn�M havr, qualfied fw the deduction urMer this section when he or she was alive. �
(Age o! deceased veteran on date ol death I
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� �] Applicarri is a veteran ot Wald War I.
�'Applitant's disadLty is eviderxed by. ❑ Lener from Veterans Administra�on or Depamrr.nt d Detense; or
- ❑ DiSdwge eavments
C. ❑ The assessed valuaaon (at 700°6) of the property for wMCh the deduction is daimed (may not exceed 8163,000) 5
D. ❑ The property is ihe appGcant's prfruipal residence. .
E. 0 The apd'xant owned tice property (or was buyirg i! ur�der ow�6act) fa at leasi one year before the date of this appGration.
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