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�t "rcn�!7umber 12A - Revised 1977 � � � ,� `'�
�-Prescribed by State Bcrard of Tax Commissione1 r� �� 2((1
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITYO��
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and Application for Deduction From the
Assessed Valuation of Taxable Property
*** Qua ifications On BacY, ***
STATE OF INDIANA iC.� COUNTY,
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(Name) ��,i, �, � %v��, , being duly sworn on oath says
that (s)�is �/� years of age; that (s)he resides at
in �i�� County, Zndiana; that (s)he
Check One: _�was 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 wno has been honorably discharged thereirom 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 � yj� �14..�F� TJL�'�BI�A.A.� �`��
Award of Compensation or V � g_��
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter sta.teme.n.t_o.f ten percent disability or more from the
Departi - Board of the
� approp� I
� exhib
►
� hat ���Qsll
� ' p�
��� (not �a il.�
( ation ofP`�TSeTO
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to wit:
TAXING DZSTRI
LEGAL DESCRIP
That, in a
for in this C
in
9/`�-0O.33c� � Qi�-�?5
Q1/1.�x.a�� d-o �/f%Cl.c�.c�
���� ti� t/lza�/i_-Q� ��LCL(t�
9-ia-oa
l99� o00
:aining�$
. assessed valu-
he year 19�,
duction applied
deduction
axing District.
Applicant/Guardian
Subscribed and sworn to before me, and disability verified this �
d a y o f � R�4�-�� , 19 �
cr�/. D . �.ti-+�.c.�-��
Auditor
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