Veterans_BurnsForm Number 12A - Revised 19�I!
Prescribed by State Board of Tax Commissioners /�/�/� ,/�
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' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY �l d
and Apolication for Deduction From .the �/ �
� Assessed Valuation of Taxable Property
*** Quali:ications On Bac'r. * �1.
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STATE OF INDIANA �l�'Y, SS:
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(Name) , bei g duly sworn on oath says
that (s)he is � years of age; that (s)he resides at ���,(���>�{j�t.C�
_�3Q 9 �.CzlS� County, Zndiana; that (s)he
Check One: _L�as a Member of the U.S. Armed Forces during any of
its wars
w` or the widow of a member of the U.S. Armed Forces �
�\ I� who served during any of its wars
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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
.� appropriate branch of the armed forces
�exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15 �q �G -`'` o� o
/9.8�- 3�°a
That this application is made for the purpose of obtaining $�v v v
.
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 �OZ
to wit: �����
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER I�'��`�`^'� �jy"� '
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, Taxing District.
X p� � a.�.-�.
(Applicant/Guardian)
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�_ Subscribed and sworn to before me, and disab�t� �eri� is 1
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da y o f _�/,Zit !1( , 19 (�o� r.� _
MAR 1 1982 �
Auditor `
�a �'1ilJG1��
r,.� �nITOR _