HomeMy WebLinkAboutVeterans_BurrisForm Number 12A - Revised 1977 ��
Presc�.ibed by State Board of Tax Commissioners �/O 7
, 6
_ VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE�ONNECTED DISABILITY
and Apolication for Deduction From the
�: Assessed Valuation of Taxable Property
*** pualifications On Back ***
STATE OF INDIANA ��� � COUNTY,
(Name) ,i p ��,,,.� � ��(�n�,.��„ being duly
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Ss: �.
sworn on oath says
that (s)he is years of age; that (s)he resides at
?',C/ /,/LG�,tK i n
�
County, Indiana; tnat (s)he
Check One: was a Member of the U.S. Armed Forces during any of
its wars
oz 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 � 'h'
Award of Compensation or Gr
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.
�q8� - ya�°
IC 6-1. 1•12-13 and 6-1. 1-12-15 3 O� D
That this a lication is made for the /� ��
pp purpose of obtaining $�'
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 ��
to wit:
TAXING DISTRICT
r )
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ deducti-on applied
for in this County, (s)he has or intends to apply for $ deduction ���
�
in County, Taxinq District. �
�� �.�� X ��� �, ,�.�
� (Applicant/Gua�rdian)
� �, i: 1��2
SubscribedF�nd-sworn to before me, and disability verified this
� � —
d a y o f .1t9-u , 19
' pU
Auaitor