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Form Number 12A - Revised 1977 �`�dL��l / ' �
Prescribed by State Board of Tax Commissioners �
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED OISABILITY / •
Q�(O -
and Application for Deduction From the �j� ��
,� Assessed Valuation of Taxable Property
� *** pu lifications,On Bac'- ***
STATE /OF INDIANA � COUNTY, SS: �
(Name) `��. � ��. �1�;� being duly sworn on oath says
�
that (s)he is years of age; trhat (s)he resides at� ��j �.
o.e�c 346 `E� �
in 6'� County, Indiana; 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 more and is
ent�itled 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 Retirement �����
appropriate branch of the armed forces
� exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
AUG � n 1990
y� �S
That this application is made for the purpose of obt� " 0
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTZON OR KEY NUMBER v��' ". NW/y Il��-O .I� A�
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, \,�7� Taxing District.
X O�, �
( pp �ca t/G 'an)
Subscribed a d sworn to before me, and disability verified this $
l � day of , 19�
�. ,�AX A'
�,r, � Auditor
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