Veterans_Wadeai lv -1 g- Cg - a�"' -c� I. I$�l ., oa ���
Form Number 12A - Revised 1985
Prescribed by State Board of Tax Commissioners _
� ' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILI ��Y ��� �j ,�k;1
��.� �d,
and Application for Deduction From the JU�
� Assessed Valuation of Taxable Property 0 2 1999
Qualificat�ions On BacY. ***
STATE OF IANA COUNTY, 55: ��BSONGpU TY.q�DITOR
(Name) --'"'% , being duly sworn on oath says
� at )he is V years age; that (s)he resides at �� ���/
in County, Zndiana, �at"(s�h �_�
Check One: was a Member of the U.S. Armed Forces during any of
its wars
or 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 ���_i �'•�
�exhibited to the County uditor. ���
� �/r/�i
�C� s-i. i-iz-is �a s-i. i-iz-is ���o--= C=.,
� /�M ��
That this application is made for the purpose of obtaining $� U�1�
(not to exceed four thousand dollars) deduction from the valu-
ation of the following described taxable propert�% r the e r 19�:
, �. _ _ ., �^�'�'7—C�o'�IS��
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
FI
That, in addition to the above amount of � deduction applied
for in s County, (s)he has or intends to apply for $ Q�lldeduction
in County, 'Taxing District. -
11 �. . _
�
(Applicant/Guardian
�' Subs 'bed and sworn to before me, and disability verified this �
day of , 19�
�`%� i t ��`��L./V ' '
Aud or