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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WVYI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
SWta Fortn 12662 (R7 / 6-03)
PrescnEeO �y the �epartment of Local Govemment Finance �. � -n �-.-� _
INSTRUCTIONS: Please check a ro riate box es �T�
pp p () pertaining to tax deduction. (More than one box may be�checked; however, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Section 11.J. �,E_.1 �'
�ING DATES:
AL PROPERN: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLYy •� _ �� 4
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE`INDIVIDUAL �SHES TO
OBTAIN THE DEDUCTION. /� �
❑ I Totalty disa6led veteran (or vete�an at (east age 62 with atleast 10% disabiliry) w surviving spotis��Not to�excee S,000,�
Complete sections 1, V and VL (IC 6-1.1-12-14) .�� ��ccC�J �i. ,,���-v .,"�7�„ ,
❑ II Partialty service-conneaed disabled veteran OR surviving spouse - Not to exceed $12,000
Complete sections II, V and VI. (IC 61.1-12-13)
❑ III WoAd War I Veteran - Not to exceed $9,000
Complete sections III, V and VI. (IC 6-7.1-12-17.4)
❑ IV Surviving spouse of Wortd War I Veteran - Not to exceed 59.000
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Comolete seaions IV. V, and VI. (IC 6-1.1-12•16)
Name of ap i (fi t midd last) �` —�
Addres ( e er,city ndstate) ` , e County •
V
Applicant ( does I d�e�no!-j own property with another individual(s) besides spouse andlor another veteran.
This applicaGon is made for Me purpose of obtaining $� U�� v deduction from the assessed valualion of the following described taxable
prope for ihe year 20
Tabng Di (c1(y, town, w hip) Is theywperty in QuesUon: parce _Ke . 6er_ /�
8 Real Property ❑ Mobile Home pC 6-1.1-7) �• _ �_ _,O,a�o„ �'Q'�j�,/
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�Appfirant was a member of the U.S. Artned Forces for at least 90 days (/rot necessardy duArg war 6me).
Applicant vras hmaably disdiarged.
C. � Applicant is: ❑ Totally disaWed; a -
❑ At least age 62 with at least 10% disability
D. 0 ApplicanYs disabtiry is evidenced by ❑ Certificate of eligibility (rom the Indiana Departrnent of Vete2ns Atta"us;
❑ Pension cerufirate:
❑ A�rard of mmpensatlon Gom Veterans Administratirn or DepaNnent of Defense; or
❑ Vete2ns Administration Form 20.5455'Tax Abatement Certficate'
E. � The assessed valuaUon (at 100%) of the property for whirh tha deduction is tlaimed (may rat exceed 3773,000) S �
F. ❑ Applipm is the surviving spouse of an individual who waAd have qualfied for the deduction under ihis se�AOn when he or she vrds ative.
(Age oI deceased vete2n on date oldeath )
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A❑ Applipnt was a member o( lhe U.S. Artned Forces during any of its wars.
B. ❑ Applipnt was honorabty discharged.
C. � Applicant has a service-connected disabiliry of at least 10% _
D. � ApplicanYs disabiliry is evidenced by: ❑ Certificate of eligibiliry from Ihe Indiana Department of Veterans Affairs;
❑ Pensan certi6cate;
❑ Award of compensalion (rom Vete2ns Administration or Department of Defense; or
❑ Veterans Administration Fortn 20.5455'Tax Abatement Certificate'
E. �J Applicant is the surviving spouse of an indiviCua� who would have Qualified tor the deduction under this sectlon when he or she was alive.
(Age o/ deceased vete/en on date of death 1
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A 0 Appluant is a veteran of WMd War I.
B. � ApplicanPs disabiliry is evidenced by ❑ letter frtxn Veterans Administration or Departrnent of Defense; or
❑ Discharge doaiments
. The assessed valuation (at 700%) of the properry for whid� ihe deduc6on is daimed (may not ezceed 3763,000) S
D. ❑ Tha properry is Ne applicanfs prindpal residence.
E. ❑ The appficani owned ihe properry (w �rds buyirg if under contraG) for at least one year hefore the date o( this appliration.
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