HomeMy WebLinkAboutVeterans_CaterForm Number 12A - Revised 1985 ��
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Appli�cation for Deduction From the
` Assessed Valuation of Taxable Property
- '*� Qualificat�ions On BacY. ***
STATE OF INDIANA ���}� COUNTY, SS:
(Name) /��� / /./ �ing duly sworn on oath says
TqL `/
�hat (s)he is %.�j years of age; that�(s)he resides at 15�� /Y C�,(/tA�
(V/�JPrndir�l% in County, Indiana; that (s)he
Check One: was a yember 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 h-as 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 Certi£icate" 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 $�C�
(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 `'���- OC'U �_/ "�C��
That, in addition to the above amount of $ yo(, 0 deduction applied
for in this County, (s)he has or intends to apply for $� deduction
in �i�oYo(� _ _ ....tCounty, /Oj//p/yt,p��/� Taxin District.
�_I • ; ' �
� t��� ' X ��, �, � � - �--
T (Appl' ant/Guardian)
�� � n 1999�
Subscribed a Ysworn o before me, and disability verified this
�/,� � 9 (/[}�
�� day of L,i, `—:_�N.c�^�� 19_
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��uditor