Veterans_MairForm Number 12A - Revised 19!! �
_ Prescribed by State Board of Tax Commissioners �
� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
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and Aoplication for Deduction From the
Assessed Valuation of Taxable Property
*** Qualifications On BacY. ***
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f STATE OF IND N w COUNTY, S5:
( (Name) � , eing duly sworn on oath says
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hat (s)he is �Z/ years of age; that (s)he resides at
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� in County, Indiana; that (s)he
iCheck One: G/ 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 �
Award of Compensation or
_�Veterans Administration Form 20-5455 "Tax Abatement Ceztificate" 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
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obtaining $ pL'Zd'9C—
(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 D
LEGAL DE
That, inMfl�d�ti�c9$!to the above amount of $ deduction applied
for in t�s�� nty (g)IG� has or intends to apply for $ deduction
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in AUDITOR County, Taxing District.
X C�VLCV-cX c+.i ��. (��Ck%
(Applicant/Guardian)
. Subscribed and sworn to before me, and disability verified this �
' day of 7 , 19 �i� �
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