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-Form Number 12 - Revised 1985 „ ��1�7_ M�.li�_��
= Prescribed by State Board of Tax Commissioners L.//o< «�� � .
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILZTY '��.
� and fipplication for Deduction From the ///
Assessed Valuation of Taxable Property .
� {�** Qualifications on Back *** Q�� p?/
' STATE OF INDIANA �),,J�)'QC/Yl COONTY, SS: �(,CIi,CL(YQG �
, DC 1�� �� � _ _ " f_
(Name? , being duly sworn n oath says
e is �D years of age; that (s)he resides at ��Q�.�ig��_
Tin �,QJ`�yV� County, Zndiana; that (s)he
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was a nurse
—� was_ a Member of the U.S. Armed Forces
��r the widow of a member of the U.S. Armed Forces
and who served for ninety or more, not necessarily during the
time of war, and has bee honorably discharged therefrom and has a total
disability and is entitled to this deduction as evidenced by:
Pension Certificate or \,,�
Awar3 of Com ensation or W
P �r`� °IP •;.' � �-
Veterans Adminis_ration Form 20-5455 "Tax Ab�t,ement�CerEi^ficate" or
L�tter statem=nt of Total Disabliity from t�he•�Depa�rtmeric�bf t:�e
Defense A'f� ,
Disability Retizemen� Board or the appropriat�J�branchg�of the
armed forces � �
. 0 . � ���
exhibited to the County Auditor.
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IC 6-1. 1-17..-14 and 6-1. 1--2-15
That tk:is appli�ation is made for the purpose of obtaining $a�
(net to exceed two *..housand doilars) deductior. from the assessed valua-
tion of the follo:°ing described taxable prooerty for the year 19�, to
wit:
TAXING DISTRICT �CZTY� TOWN, TOWNSHIP) �Q^� `
LEGAL DESCRIPTION 7R KEY NUMSER
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 and that
the to*..al assessed valu� of all his/her taxable property as shown by the
tax duplicates of all countiss in which they own property is $
(Applicant/Guardian)
Subscribec and sworn to before me, and disability verified this �
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� d a Y o f, �['PJ'� ' 19 " �(�(/�/7'17GJ Gy�/ :
�� Auditor � �