HomeMy WebLinkAboutVeterans_MountsForm Number 12A - Revised 1985
Prescribed by State Board of Tax Commissioners
o�y-a��.39 . .
VETERANS, R THEIR WIDOWS STATEMENT OF SERVICE-CONNECTED DISABILITY :
,� and Application for Deduction From the
Assessed Valuation of Taxable Property
'** Qualificat�ions On BacY, *'�*
STATE OF INDIANA �Z'��� COUNTY, SS:
(Name) ✓np,(/)7/ (1) i0 �/„j,i M.�J , being duly sworn on oath says
that (s)he is years of age; that (s)he resides at
� �n (�,��� County, Indiana; that (s)he
�'�� � �,�
C ec ne: was a Member of the U.S. Armed Forces during any of
its wars
x 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 Reti�rement 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 $ ynn0
(not to exceed four 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 /�DA.I� �n�.� 4-
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
f,s„✓ � / /� "�
(A licant/Guardian)
• Subscribed and sworn to before me, and disability verified this��
day of �('�� , 191� •
��' V � ��
Auditor �