Veterans_Bilderbacki��, •'�
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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
1NWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fortn 12662 (RB / a-04)
Presuibed by the Depanment ot Local Govemment Finance
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InISTRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; howeve� a surviving
spouse who receives a deduction under Section IV may not receive a deduction unde� Section ll.)
�'JG DATES:
REAL PROPERN: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION.
❑ I Totally disabled veteran (or veteren at least age 62 with at least f0% disability) or surviving spouse - Not to exceed $12,480
Complete secUons I, V and VI. (IC 6-1.1-12-14)
❑ II Partially service-connected disabled veteren OR surviving spouse - Not to exceed 524.960
Complete sections II, V and VI. (IC &1.1-12-13)
❑ III WoAd War I Veteran - Not to exceed 818,720
Complete sections Iil, V and VI. (IC 6-1.1-12-77.4)
❑ IV Surviving spouse of World War I Veteren - Not lo exceed 578,720
Compiete sections N, V, and VI. (IC 6-1.1-12-16)
Name of appli irst, middle last)
Address (street aqQ number y, sfate, ZIP ode) � � h,
CJ(
Applicant ( does / does not � own property with another individual(s) besides spouse and/or another veteran.
This appliwGon is made (or the purpose of obtaining 5 deduction from the assessed valuation of the (ollowing desctibed W�cable
property for the year 20 � -O � O—
Tazing District (city, town, fownship) Is the operty in question: Pa e number
Real Property ❑ Mo6ile Home QC 6•1.1-7) � .�O
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�� Applicant was a member of the U.S. Armed Forces (w at least 90 days (not necessanty dunng war fime).
B. � Applicani vras hono2bly discharged.
C. ❑ Applicant is: ❑ TotaVy disabied; or
❑ At least age 62 with at least 70°/, disabiGty
D. 0 P,pqipnYs dsaWlity is evidenced by. ❑ Cerlifipte of etigib�ity from the Indiana Department of Vele2ns Af(airs;
❑ Pension certifipte; � �
❑ Award of compensation from Veterans Administration or Department of Defense; or
❑ Veterans Administra6on Form 20.5455'Tau Abatement Cerlifipte'
E. ❑ The assessed valuation (at 100°/ ) of the property for which ihe deduction is daimed (may not exceed 5713,000) $
F. � Appliont is the surviving spouse of an individual who vrould have qualified for ihe deduction under this section when he a she vras alive.
(Age of deceased veteran on date o! death )
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A. 0 Applirant was a member of the U.S. Armed Forces during any of its wars.
B. � Applicant was honorably discharged.
C. ❑ Applicant has a service-connecled disability of at least 10%
D. � ApplicanCs disability is evidenced by: ❑ Certificate o( eligibility from the Indiana Department of Veterans Aftairs;
❑ Pens" certifcale;
❑ ard o( compensauon from Veterans Administretion or Department of Defense; or
Veterans AdministraUon Fortn 20-5455'Tax Abatement Certificate'
E. ❑ Applicant is the survrving spouse o( an individual who would have qualified for the deduclion under this section when he or she was alive.
(Age o/deceased veferan on date of death 1
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A 0 AppGpnt is a veteran of Worid War I.
�l AppGCanYs disabiGty is evidenced by: ❑ Letter from Veterans Administratlon or Department of Defense; or
❑ Discharge documents
C. � The assessed valuation (at 100%) of the property for which ihe deduction is daimed (maynot ezceed 5163,000) $
D. 0 The property is the applipnts prindpal residence.
E. ❑ The appliqnt owned �he property (or was buying it under conhact) (or at leasi one year before ihe date of this application.
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