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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fortn 12662 (RS / 8-0O)
Prescribed by the State Board of Tax Comrtussioners
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�RUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduc6on under Sectron 11.)
THIS APPLICATION MUST BE FILED DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
❑ I Totally disabled veteran (or veteran af least age 62 with at least f0% disability) or surviving spouse - Not to exceed 56,000
Complete seGions I, V and VI. (IC 6-1.1-12-14)
❑ II Partialy service-conneded disabled veteran OR surv'rving spouse - Not to exceed $12,000
Complete sedions II, V and VI. (IC fr1.1-72-13)
❑ III World War I Veteran - Not to exceed 59,000
Complete sections III, V and VI. (IC 6-1.1-12-17.4)
❑ IV Surv'rving spouse o( World War I Veteran - Not to exceed 59,000
Complete sedions N, V, and VI. (IC 6-7.1-12-16)
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Name of applicant � mi le, las� • Date of 6irth (month, day, yea�
Addr ss st et an umb city and ate Zip code Coun
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Applicant ( does I does not ) own property with another individual(s) besides spouse and/or another veteran.
This application is made for fhe purpose of obtaining $� ��D dedudion from the assessed valualion of the folowing described taxable
property for the year 20
Taxing Distrid (city, town, township) Parcei or Key number
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A L] Applicant was a member of the U.S. Armed Forces (or at least 90 days (not necessarify dunrg war time).
8. ❑ Appl'�cant was honorably discharged.
C. ❑ Appficant is: ❑ TotaOy disabled; or
❑ At least age 62 wifh at leasl 10%disa6iliry
D. ❑ AppGpnPs disability is evidenced by ❑ Certfipte of eGg�bility from the Indiana Departrnent of Vete2ns AfFairs;
❑ Pension certifipte;
❑ Award of compensation Bom Veterans Administration or DepartmeM of Defense; or
❑ Vetewns Administration Form 245455 "Tax Abaternent Certificate'
E. � The assessed valuation (at 100%) of the property for which the deduratian is dairt�ed (may not exoeed 554,000) $
F. � Applipnt is the surviving spouse of an individual who vrould have qualfied tor the deduaion under this sedion when he a she was afrve.
(Age o/deceased veteran on date ofdeetl� )
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A 0 Applicant was a member o( the U.S. Artned Forces during any of its wars.
B. � Applipnt was honorabty discharged.
C. 0 Applicant has a servirzconneGed disability of at I �o
�D. ❑ ApplicanYs disability is�evidenced by: rlificate of eligibiliry from the Indiana Department of Veterans Niairs;
❑ Pension certificate;
❑ Award of compensation from Veterans Administration or Departrnent of Defense; or
• ❑ VeteransAdministrationFOrtn245455?axP,batementCerlifinte'
E. ❑ P,pplicant is the surviving spouse of an ind'rvidual who would have qualified for the dedudion under this section when he or she was alive.
(Age ofdeceased veteran on date o/deafh )
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�� Applicant is a veteran of World War I.
J P,pplionPs disability is e�ridenced by: ❑ Letler trom Vete2ns Administration or Departrnent of Defense; or
❑ Distliarge documents
C. � The assessed valuation (at 100%) of Ne property (or which the deduption is davned (may rat exceed S78,W0� E
D. O The property is the applicanPs prindpal residence.
E. ❑ The app6cant avned the property (or was 6uyirg it under con6ac� for at least one year be(ore ihe date of this application.
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