Veterans_SchaferI�
Form Number 12A - Revised 19!! ^^,��
Prescribed by State Board of Tax Commissionera d� �j
4
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
� :' and Aoplication for Deduction From the
� Assessed Valuation of Taxable Property
*** Qualifications On BacY. ***
STATE OF INDIANA ��/i✓J.n-�c COUNTY,
� � ��
/
(Name) �/t,f��� �/� being duly sworn on oath says
that (s)he is years of age; at (s)he resides at ���/j��f/_
/C_ �/��.a a in County, Zndiana; that (s)he
Check One: � was a Member of the U.S. Armed Forces duzing any o`
its wars
or the widow of a member of the U.S. Armed Forces
who served during any of its wars
and wno 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.
ic s-i. i-ia-ia a�a s-i. i-i2-i� /9�lv '�30 o a
9 �'� -
That this application is made for the purpose of ob �ining $�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 C��
to wit:
TAXING DISTRZCT
LEGAL DESCRIPTION OR KEY NUMBER %�(�� �jJ�
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
� ��LAAAO � aC��[, I} � Af . ° �
, (Applicant'/ )
��� � Subscribed and sworn to before me, and disability ver�;�'x�ed t� _
p�7 I.: L
�.ay of �/,�� � , 19 O �r i� /
�' J� . � , I�tJCl�1�
, AUDITOR
Auditor
.
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