Veterans_Cox,FOrm Number 12A - Revised 1985 '� __ ; � �'y 1
Prescribed by State Board of Tax Commissioners 7��J
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE�CONNECTED D�I�I� ���
1l
•5 and Application for Deduction From the � 1 7
.. Assessed Valuation of Taxable Property .�R 29 1991 �
**� Qualificat�ions On Back ***
STATE OF INDIANA ��.,�L7Q.�� COUNTY/7��
. n i �,�acnn! COU� . Y t.i1t1170R .
(Name) �,� ��e�s�, �..� Tt��... , being duly sworn on oath says
�hat (s)he is ��years of age; that (s)he resides at� �� 3�I
in ,4 � �-�1 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 who has been honorably discharged therefrom and has a service-
connected disability of ten percent (10 percent) or��}o�e and is
entitled to this deduction as evidenced by: v� U
Pension Certificate or \O�� �
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 $��_
(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
v
LEGAL DESCRIPTION OR KEY NUMBER �jC " OOa.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 '� Q�.��1 County, (��-y,\D1J��� (' �v Taxing District.
X ��P.�_ �'��
(Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this ��
day of [� ,�,v , 19�.
oa. )1���.1ls.a�
Auditor