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corm Number 12A - Revised 1977 � �
P:escribed by State Board of Tax Commissioners �I 3— d0 �
�V VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE�ONNECTED AB TY �� �
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and Application for Deduction From t �' � /�/
(O
� • Assessed Valuation of Taxable Propert
+** Qualifications On Bac'r. ***
1
STATE OF INDIANA ;��� ' COUNTY �
(Name) � . , being duly sworn on oath says
that (s)he i�Q years o: age; that (s)he resides at,��t,�� •/�
in �a��� 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.
�
re s-i. i-iz-ia �,a s-i. i-i2-i� /9�� �� o o D
� 9?y - 3 00 0
That this application is made for the purpose of obt�ining $�
(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 DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER �,Q..a� ����L
Tha� � s�d�� the above amount of $ deduction applied
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for in h' �'P.s�tl he has or intends to apply for $ deduction
in �,�pp q q'�G�? County,
�� �.�i'css� °���.�
(;UDITOR
Subscribed and sworn to before me,
/I �
Taxing District.
nt/Guardian
disability verified this �.3
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