Veterans_HallForm Number 12A - Revised 1985
Prescri�e�i:�'by State Board of Tax Commissioners
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABIIT•Y'�I
�j and Application for Deduction From the �Y�`�� �
� Assessed Valuation of Taxable Property [ta O 2 199s
*** Qualifications On BacY. *** �L
STATE OF INDIANA COUNTY, SS / �1 � /e( �
t�l J ��-�-(J�
�l-+/': i.. � �.
G o:8S0i! �CUtiTY C.:,'CITG6
(Name) , being duly sworn on oath s ys
�hat (s)he is �/� years of age; that (s)he resides a
in }� f V� County, India���h� (��
—��
Check One: was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a menber 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
y�`'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. 1-12-15
That this application is made for the purpose of obtaining $ DQQ.O�
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 ,
to W�t: ^ �^� � Oly- dbl`1'�-�a�,�oa-�3�
TAXING DISTRICT �p /Z QQ �JJ�"' __ __
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ a � Q deduction applied
for this County, (s)he has or inten s to apply for $�� 0 deduction
in County, Taxing District.
X �c%c�°� � fi�.�ee�
(Applicant/Guardian)
� Subscr bed and sworn to before me,
day of ' , 19�.
and disability verified this o� y.
f(
W�
Auditor
•
1/1 Department of
Veterans Affairs
575 N PENNSYLVANIA ST JANUARY 30 , 1998
INDIANAPOLIS IN 46204
( '
WILLIAM F HALL
PO BOX 125
HAZLETON IN 47640
.
,Tax Code 3: Pension to veterans for disabilities of non-service
-origin considered totally disabling and death pension or
compensation to surviving spouse.
NOTE: INQUIRIES CONCERNING YOUR ELIGIBILITY FOR TAX ADJUSTMENT SHOULD BE DIRECTED TO TIIE
TAXING OFFICE RESPONSB3LE FOR GRANTING THE BENEFIT.