Veterans_Roethemeier%a '
APPLICATION FOR TAX DEDUCTION FOR DISABLED VE'iERANS,
YVWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
SWte Fortn 12662 (R7 / 6-03)
PrescnCed by Ne Department of Local Govemmen[ Finance
INSTRUCTIONS: Please check appropriate box(es) pertaining to tax deductlon. (More than one box may be checked; however, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Section 11.)
+G DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION ISIO APP,L,Y., ,��
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICFi THE'1INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION. �a (j rj , F� ��/
.:1 11.�d
❑ I Totally disabled veteren (or veteran at least age 62 wrth atleast 10% disabtiiry) or surviving spouse - Not to'} exceed 56,000
Complete sections I. V and VI. (IC 6-1.1-12-14) J U L 5' L�u4
� II Partialty servica-conneaed disabled veteran OR surviving spouse - Not to exceed $12,000
Complete secUons II, V and VI. (IC 6�1.1-12-13) J
, ❑ 111 Wodd War I Veteran - Not to exceed $9,000 ��_., �-� ./ � _te
� Comolete sections III,-V and VL (IC 6-1.1-12-17.41 �'` "�=' ' . " ' '
❑ IV Survivin9 spouse oi World War I Veteran - Not to exceed 59,000
Comolete seclions IV. V. and VI. (IC 6-1.1-12-161
Name of pplicant (first, middle, last) �
Address (st et and number, ciry an st te) Zip code County
0
Applicant ( does I does not ) own property with anoNer individual(s) 6esides spouse andlor another vetaran.
This application is made for the purpose of obfaining $� 7 7�D deduction trom the assessed valualion of the following described taxable
property for the year 20 Q
Taxing DisVict (city, town, township) Is,-,th�e property in question: Parcel or i(ey number� '
LYtteal Property ❑ Mobile Home (IC 6-1.1-7) Q� _ o � a-�
• . . � . � • ' � ' � � . .
Applipnt was a member of the U.S. Armed Forces for at least 90 days (not necessa/dy dunng war tlme).
B. ❑ Applipnt vras hmorably distharged.
C. ❑ Applicant is: ❑ Totalty disaWed; or � �
❑ At least age 62 vrith at least 10% disa6ility
D. � AppliwnYs disabiliry is evidenced by ❑ Certfirate of eligibility from Ne Indiana Department W Veterans Af(airs;
❑ Pension certificate;
❑ Award ot compensation from Veterans Administratlon or Department of Defense; or
❑ Ve[erans Administration Fortn 20-5455 "Tax Abatement Certfiwte'
E. � The assessed valuation (at 100%) of Ne property fw vfiiG� Me deductim is da"uned (may rwt exceed $173,000) $
F. ❑ ApplipM is Ne surviving spouse of an individual who wadd have qualified for the dedudion under tliis secuon when he or she was alive.
(Age o/deceased veteran on date o/death )
� . � . .
A. ,,_, A�p licant was a member of the U.S. Artned Forces during any of its wars.
B. �,e�Ap �cant was honorebly discharged.
C. icant has a service-connected disabiliry of a ast 10%
D. ApplicanYs disability is avidenced by �rtifirate of eligibility from the Indiana Department of Veterans AHairs;
❑ Pen ion certificate;
Award of compensation (rom Veterans AdminisUation or Department ot Defense: or
� Vete2ns Administration Form 20.5455'Tax Abatement CertiScate'
E. ❑ Applicant is Ne surv'rving spouse of an individual who would have qualified for the tleducUon under this section when he or she was alive.
(Age o! deceased veteran on date oI death )
• . .
A❑ Apdicant is a veteran of World War I.
� ApplicanTs disabiliry is evidenced by ❑ Letter hom Veterans Administratlon a Departrnent of Defense; w
❑ Discharge documenis
C. ❑ The assessed valuaaon (at 100°b) of Me pfoperry fwwhidi the deduction is daimed (meyrat exceed 3163,000) 5
D. ❑ The ptoperry is the apd��nYs prindpal residence.
E. � The appGpni ovmed the properbj (or wds 6uyilg it unde/ contract) fw at least one year before ihe date of this applintion.
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