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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
W1NI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
Slate Fwm 12662 (R6 / 70-07)
Presaibetl by ihe Department ol Loral Govemrtreni Finance
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TRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one 6ox may be checked; however, a surviving
spouse who receives a deduction under Section IV may not ieceive a deduction unde� Section ll.)
uNG DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (61.1-7): BETWEEN JANUARY 15 AMD MARCH 31 OF THE YEAR THE DEDUCTION IS TO BE EFFECTIVE.
❑ I Tatally disabled veteran (or veteran af least age 62 with at least 109; disability) or surv'rving spouse - Not to exceed 56,000
Complete sections I, V and VI. (IC 6-1.1-12-74)
❑ II Partialty service-conneded disabled veteran OR surviving spouse - Not to exceed 572,000
Complete sections II, V and VI. (IC Cr1.1-12-13)
❑ III World War I Veteren - Not to exceed 59,000
Complete sections III, V and VI. (IC 6-7.1-12-17.4)
� IV Surviving spouse oi World War I Veteran - Not to exceed $9,000
Complete sections IV, V, and VI. QC 61.1-12-i6)
Name of applipnt (fi middle, las�
Addres st et a number, city and state) , Zip code County .
Applicant ( dces / does not ) own property with another individual(s) besides spouse and/or another veteran.
This application is made for the purpose o( obtaining $� a•� deduction hom the assessed valua6on of the foiowing desaibed taxabie
property, for Ne year 20�.
Ta�cin istriC (city, town, township) Is�the�° peRy in question: . .� P rcel or ey number �
.. L�Real Property ❑ Mobile Home pC,6-1:1_7) �� — � . - O_ — �Q { ,
e . . � . . � ' . � � � ' . . . �
�. L7 Appticard was a member of the U.S. Artred Forces for at least 90 days (rrof necess.viy dunrg war time).
B. � App6ranl was honaraby d�alged. .
C. ❑ Apptipnt is: ❑ TotaDy disabled; or
❑ At least a9e 62 with at least 10% disability
D. � ApplkartYs disab8rty 6 eviden�d bY ❑ Certifipte of eligibiliry 6om the Indiana Department o( Veterans Affairs;
❑ Pension certifi�ate;
❑ Award of compensation 6an Veterans AdminisVation or Departrnent of Defense; or
❑ Veterans Administration Fortn 20.5455 Tax Abaterrient Certifinte'
E. � The assessed vah�ation (at 100%) of the property for which the deduptbn is davred (may rat exceed S54,OOOj $
F. ❑ AppGpnt is the wrviving spouse of an individual who would have qualfied for the dedud"an under this seUion when he or she was alive. �
(Age o)deceased veteran on dafe o/deeth 1
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A❑ Applinnt was a member of the U.S. Armed Forces during any of its wars. �
B. ❑ Applipnt was honorably discharged.
C. ❑ Appliwnt has a service-conneded disabiliry o( at Ieast 10°�
D. 0 ApplicanYs disabiliry is evidenced by: ❑ Certifidte of eligibility from the Indiana Department of Veterans Affairs;
❑ Pension rtifiwte;
❑ A of compensation from Veterans AdminisVation or Department of Defense; or
eterans Administration Fortn 20.5455'Tax Abatement Certifipte'
E. � Applipnt is ihe surviving spouse of an individual who would have qualified for the dedudion urMer this section when he or she was alive. .
(Age o/deceased veferan�on dafe of death 1 "
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�AppticaM is a veteran of World War I. -
� AppticanYs disabildy is evidenced by. ❑ Letter from Veterens PdminisVation or DepaM�ent of Defense; or
❑ Disdiarge dowments �
C. ❑ The assessed valuation (al 100°,6) M the property for whi�h the deducation is da�ned (mey not exceed S78,OWj $ -
D. 0 The property is the applinnYs prindpal residen�.
E. � The appficaM owned the propeAy (or was buying d urder oonbacf� for at least one year before the date of this application.
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