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Veterans_MartinForm Number 12A - Revised 1977 �,}.
' Prescribed by State Board of Tax.COmmissioners U
`�( 1' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
��,y� and Apolication for Deduction From the
�• �� Assessed Valuation of Taxable Property
�
*** Quali/�/,�y� cations On Back ***
STATE OF ZNDZANA �S.'`��Qlr„/ COUNTY,
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a -.�"
%� �°
(Name) � �� % , being duly sworn on oath says
� that (s)he is �� years o: age; that (s)he resides at �
\ 30Q F F�rx� A3�- • County, Indiana; that (s)he
Check One: �as 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 '
• exhibited to the County Auditor. ^
IC 6-1. 1-12-13 and 6-1. 1;12-1�
That this application is made for the purpose of
/q�� - �o 0 0
�y Pi� - 3 � ° °
btaining $�—
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19��,
to wit:
TAXING DZSTRICT
LEGAL DESCRIPTION OR KEY NUMBER ����� f��e �/��i- ,
. �
That,�i,n addition to the above amount of S deducti�on applied
J �ga �i
for in tL�s��uptf�,' s) e has or intends to apply for $ deduction '
�.s �.a
in �p �� County, Ta �n�g Distr�ict.
T7r
�1 X � J
��S�a�,��' -n (Applicant/Gu rdian)
!'.UD!TOR 5•�x
�Subscribed and orn to before me, and disability verified this ��
'
' d a y o f � Q,.,�,Y,� , 19 �o�
/� d . �r
Auditor
.
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