Veterans_LewisForm Number 12A - Revised 19l'/ ��j
Prescribed by State Board of Tax Commissioners
'- �_ +VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY u
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'"and Aoplication for Deduction From the .
Assessed Valuation of Taxable �Prooerty
*** Qualifications On BacY. ***
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STATE OF INDIANA ����pj� COUVTY, SS:
(Name) , beinc duly sworn on oath says
that (s)he is � years of age; that (s)he resides at" ��„ ���.,h
�
in �aQj�j�� County, Indiana; that (s)he
Check One: �� was a P7ember of the U.S. Armed Forces during any of
, its wars .
or 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 �
�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.
cc s-i. i-i2-is �,a s-i. i-i2-i� ���Q��_ y°O'�
y_ 3000
That this application is made for the purpose of obtaining $ a�-���
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19t��
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER ��`j �Q��c.�� ..�Y ��C
That, in,addition to the above amount of $ deduction applied �
,\.•
for in this County, (s)he has or intends to apply for $ deduction
in ��� �/V� County, � �U • � . Taxing District.
v g � � � �L 9 X �li�"�--j�� / / " � •
(Applica / a dian)
� Subscribe d s A to before me, and disability verified this O
��� $ ���- —
day of , 19��
� AUDITOf: ' I °� ��-CA-I.IIf v�1�2}ml
�. Audito
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