Veterans_Robb�
Form Number 12A - Revised 1977 ,L�
Prescribed by State Board of Tax Commissioners ��� T
^ '� VETERANS, OR THEIR WIDOWS. STATEMENT OF SERVICE-CONNECTED DISABILITY I��
and Apolication for Deduction From the �
Assessed Valuation of Taxable Property 1�
*** Qualifications On Bac'r. ***
(r7ame) y�QQ,�,�, W(��r , being duly sworn on oath says
that (s)he is L years of age; that (s)he resides at �' 2n m.
�v�Q��'�3 in ���m County, Indiar�� that-(
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 d.isability oF ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
Pension Certificate or �O"IO �
�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 � �
�exhibited to the County Auditor.
9�G - yoeo
IC 6-1. 1-12-13 and 6-1. 1-12-15 ���_
3O0 a
That this application is made for the purpose of obtaining $�
(not to exceed two thousand dollars) deduction from the assessed valu-
0
ation of the following described taxable property for the year 19�
.
��i ° _ � � rC..�l„h •
LE�dA� LbES�B�gPTION OR KEY NUMBER �Q /y � � . � ���
�oT t, i d'tion to the above amount of $ deduction applied
�
g�UD�O�i County, (s)he has or intends to apply for $ deduction
in � '(��� County, �}���Jv� Taxing District.
X -%r�,.�.�Le..�- 4v_ /�oQ.�"
(Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this
� day of � � LI ( , 19$�.
I-f � U • Gt,cy..«i,.�
Audit r
.
�'
� �.
.�