Veterans_HaworthFo'tm Number 12A - Revised 1985 ��
�:,-Prescribed by State Board of Tax Commissioner
�� .
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISA�I�T����
and Application for Deduction From the
.� Assessed Valuation of Taxable Property
*** Qual' icat�i.ons On BacY **' MAY iU 19gg
STATE OF INDIANA � COUNTY, SS�• •._�{'�i
�•l•iJ {
'�C��r . y'rY �� �1
(Name) ( - � , being duly sworn -"o'n oa� g9a s
�hat (s)he is � years of ge; that (s)he resides at 1,/ �
n� 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
entitled to this deduction as evidenced by:
Pension Certificate or
�ard 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 $�(`�Q�
(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 `(�LI� U��-��-�0
Oo
That, in addition to the above amount of S�-�Q�p— deduction applied
for in t i•s County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
i
X �
pp i ant/Guardian)
� Subscribed and sworn to before me, and disability verified this _
f
d a Y o f � � 19 � (�/n (.� / ��/���-"'�� "`�'
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Auditor