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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
W4VI VEYERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS
State Form 12662 (R9 / SOB)
Prescribed Dy Ne Departmen� o( �ocal Govemment Flnance
'�UCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduct' n d Se l.
FILING DATES: � � � �
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE11 Of THE YEAR THE DED O IS O A L
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR- R I H I AL WISHES TO
OBTAIN THE DEDUCTION. F 9'p
❑ i Totally disabled veteran (or veteran a(least age 62 vnth at least 70% disa6ility) or survivin��spou� -BNdtYoOe�xceed 572,48G
Complete sections I, V and VI. (IC 6-1.7-12-14) ��n �
❑ II Partially service-connected disabled veteran OR surviving spouse - Not to exceed 524,96v���6� �/�.
Complete seUions II, V and VI. (IC 6-1.7-72-73) ��
❑ III Wodd War I Veteran - No� to exceed 578.720 dIB9bN COUNiY AUBIT9�
Complete sections III, V and VI. QC 6-7.1-12-17.4)
❑ IV Surviving spouse of World War I Veteran - Not to ezceed 518.720
Complete sections IV, V, and VI. (IC 6-1.1-12-16)
Name of applicant (fi , iddle, st � � Date of birth (monN, day, year�
Address (streef and �µm�e � ZI County
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Appliwnt ( dces 1 dces not ) own property with ano�her individual(s) besi es spouse and/or anoNer veteran.
This application is made for the purpose of obiaining $ deducUOn from the assessed valuatlon of the fdtowing described taxable
property forihe year 20_ . �
Taxing is c wn,, ro,,,wn�� jhiry8) Is the p m quesUon: Parcel or Key Onumber / q/��
� � �V �.KA` eal Property ❑ Mobile Home (IC 61.1-7) p2(p— I / — (p—,3Q �—���.(nO /v
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A Ll Appfirant was a member of tl�e U.S. lvmed Faces for at least 90 days (rwt ncoessarily dunng warOme�
B. ❑ /+�f'i�ant vrds iraaraby disdiarged.
�C. � App6cant is: ❑ TWaOy disaded; a ..
❑ At Irast age 62 with at least 10% disabitily
D. ❑ AppliranYS disability is eviderxed by ❑ Cuti(rate W e6gibtlity from tlre Indiana Departrnenl of Veterans AHa"us:
❑ Persim �+tifitate;
❑ Avrard of cwnpensalim frwn Veterans Adrtmdstration or DepaMient of Defense: a �
_ / ❑ Veterans Administra�on Form 2O-5455 "Tax Aba[emerrt Celtifirate'
E. ❑. I qe assessed valuation (at 100%) of ihe property for whidi the deducUon is daimed (may not exceed 5773.000) S
F. ��Applinnt is the survivcig spouse of an individual who wwld have qualified tor the deduction under this section when he w she v.as alive.
(Age ol deceased Heteran on dafe W death )
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A Q Applirant was a member of the U.S. Artned fwces during any of its wars.
B. ❑ ApPlinnt was ho'mrably discharged.
C. � Applipnt has a service-connecled disability of al leasi 10%
D. 0 Applicant's disabiliry is evidenced by � Certificate of eligibility from the Indiana Departrnent of Veterans Aflairs;
❑ Pensbn certificate; -
� A�rard of mmpensa6on from Veterans AdminisVaSOn or Department of Defense; or
❑ Veterans AdminisVaGon Form 20.5455'Tax Abatement Cer6ficate'
E. O Applicant is ihe surviving spouse of an indiviAiial whn wrndrt havr, qualified for the deduction under this section when he or she was alive.
(Age o! deceased veteran on date d death )
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�rl Applinrri is a veteran d WMd War i.
Applicarrt's disabdAy is eviderxeA by: ❑ Letler from Veterans Administrauon or Department d Detense: or
❑ Drs�hafge dowments
C. � The assassed valuation (at 100°,6) of ihe properry tor vAudi Me deduction is daimed (may rwt exceed S 763,000) 5
D. ❑ The property is ihe applicanYs prindpal residence.
E. ❑ The appfwant owned the prop�ry (a was buying i1 u�der oon6aG) fw at leasf ine year before the date of tlus apptication.
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