Veterans_Wright-FOrm Number 12A - Revised 1985 �� '
Prescribed by State Board of Tax Commissioners �tryu• ��� �
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABIL}TY
r��L 12 1993
� and Application for Deduction From the
Assessed Valuation of Taxable Property
**• Qualifications On BacY. **" �""" pUDITOR�s
STATE OF INDIANA ./p�'lJ-'�,�yl_J COUNTY, S5:
(Name) , being duly sworn on oath says
�hat (�he is years of age; that (s)he resides at 3Q� S• J��DST,
��AJ-(/y(,Of}y�Q�( in ���}�}-yL� 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
� 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.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19_,
to wit: ^ n ,�
TAXING DISTRICT @ �ANM�.�Fl A X..L
LEGAL DESCRIPTION OR KEY NUMBER c���o—�-a9_a�o�
That, in addition to the above amount of $ deduction applied
D�
for in this County, (s)he has or intends to apply for $ deduction
in County, ��.lj'e/N4.lil_X_�� Taxing District. '
��--�'����--s�-
(A plicant/Guardian)
. Subscribed and sworn to before me, and disability veriiied this I��
day of . 19�• �
��
Aud' or
".