HomeMy WebLinkAboutVeterans_RossForm Number 12A - Revised 19i7 ��
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
/� and Aoolication for Deducti�on From the
� ./V 1 Assessed valuation of Taxable Property zJ �
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� � *** Qualifications On Back *** �J
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STATE O�INDIANA o%1�[�/Y� COlitdTY, SS:
(Name) �,(xxy/y� ��-, _ � QdA , being duly sworn on oath says
that (s)he is
years of age; that (s)he resides at ���(��Q
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in ,�1Q�m(j��s,�,, 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 sezved during any of its wars
and wno 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 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. o
IC 6-1. 1-12-13 and 6-1. 1-12-1� �o� ` �� OD
��8�- 30� o
That this application is made for the purpose of obtaining $�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation o�h� �o_�� described taxable property for the year 19�,
di� �,��
to `"it: 198� /� ,(� /�
TAXING DIS���1 �J\/`J(�Qy
LEGAL DE��
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NUMBER ROa�� ��9]
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That, inH`��3ition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction ��
in County, Taxing District.
X��z�
(Applicant Guardian)
� Subscribed and sworn to before me, and disability verified this ���
day of m(�,u_, , 19��
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