HomeMy WebLinkAboutVeterans_Hicks'�' For� Number 12A - Revised 1985 \�._ �
•�Prescribed by State Board of Tax Commissioners �X
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VETERANS. OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABIL����� �•- :
"'� .ily
��� and Application for Deduction From the
Assessed Valuation of Taxable Property
*** Qualificat�ions On BacY "*
STATE OF /I"�NDIANA �A_l� COUidTY,
(Name) TVQn� `'� � , �,�A1 , being duly
�
�hat (s)he is years of age; that (s)he resides
in Y
i��� � �J�a
55: �'�`qUDITOR' S
sworn on oath says
at Q�O.� �f�
County, Indiana; that (s)he
Check One: �was a Membez 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
��etter 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 6-1. 1-12-13 and 6-1. 1-12-15
n,n!� bA
That this application is made for the purpose of obtaining $ ��1�
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 `'r-�,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBE�:�_�1�
That, in addition to the above amou�of
deduction applied
for in thi County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
X �OC1a n. ` �!// .S"5ia � �.�
(Applicant/Guardian)
. Subscribed and sworn to before me, and disability verified this �
d a y o f �Ll,l.p,Jl , 19 %� •
/Y1 4 � ' `�
Audito
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S%.. , DEPARTMENT OF VETERANS AFFAIRS
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Combined Evaluation 100:percent
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