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Form Number 12A - Revised 1977 /
Prescribed by State Board o` Tax Commissioners �O Cp ��
�' �, VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Apolication °or Deduction From the �' �
Assessed Valuation of Taxable Property
*** Qualifications On Bac?: x**
STATE OF INDZANA ��,Qy,�� COUNTY, SS:
(Name) /J1MMO�i1 Q���,_A�1_M , being duly sworn on oath says
that (s)he is ��o-`years o: age; that (s)he resides at �"��d�.� ,�,�.1
� � y� Pp.�,� in �fY1 County, Zndiana; that (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 �
� 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.
�.
/9�� ' �� � °
IC 6-1. 1-12-13 and 6-1. 1-12•15 �/ 3 OQ O
That this a lication is made for the /�� T^
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 (J o`,
to wit:
TAXIN�
KEY NUMBER (�OL,Q �..�(Plf�v
Thatf;IYi�n�aii�i�ion to the above amount of $ deduction applied
for A„ R�s)he has or intends to a ,` \ \
�, �n' z� pply for $ 3eduction
AUDITOR
in County, Taxing District.
11-*-�-� ��2t,sr�:.�
(Applicant/Guardian)
Subscribed and sworn to before me, and disability verified this ��
day of m,/Z/� , 19��
�y � ��.
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