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' Po3i5 Number 12A - Revised 1985 iL�
���Prescribed by State Board of Tax Commissioners (,�II'����q /�O �{
�1 l � —v
� VETERANS OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTEDDISA�V����
and Apolication for Deduction From the �3�
�+. Assessed Valuation of Taxable ProPertY ��Ep 23 1993
*** Qualifications On Back *x*
STATE OF INDIANA ,�� COUNTY,. SS :�J /E�. ��`L�y�c
�� �X � �� AUDITOR °
(Name) y /J�yi � �, being duly sworn on oath says
�hat (s)he is �� years of age• that (s)he resides at %� �
I�1
�--`�J4ii
in �� County, Indiana; that (s)he
Check One: was a Member of the U.S. Armed Forces during any of
�its wars
or the widow of a member o£ the U.S. Arned 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 Certi�ficate" 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
That this application is made for the purpose of obtaining $ Q67
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTIO
That, in addition to the a ove amount of $ deduction applied
for in this County, (s)he has or tends to apply for $ deduction
in County, \ Taxing District.
, _ �. n �,
cant�jt'ytyardian) j� -
� —
Subscribed and sworn to before me, and disability verified this
day of , 1�•
�l�o Jv/'i�o
T Auditor
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