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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WWI VETERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS
State Fwm 12662 (R9 / SOB)
Presttibed by Ihe Departrnent W laal Govemment Flnance
�RUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (MOre than one box may 6e checked; however, a suiviving
spouse who receives a deduction under Section IV may not receive a deduction under Section 11.)�
FILING DATES:
REAL PROPERTY: DURING THE 72 MONTHS BEFORE JUNE11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION. � � � � �
❑ I. Totally disabled veteran (or veteran at least age 62 vnth a( least 10% disabilityJ or surviving se N to ex 57 480
Complete sections I, V and VI. (IC 6-�.7-72-74)
❑ II Panially service-wnnected disabled veteran OR surviving spouse - Not to ezceed 524,960
Complete seUions II, V and VI. (IC 6-1.1-12-13)
❑ 111 Wodd War I Veteran - Not to exceed 578.720
Complete sections III, V and VI. (IC 6-1.1-12-17.4)
❑ IV Survivina soouse of World War I Veteren - Not to exceed 518.720
FEB - 4 2010
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Complete sections Iv, V, and VI. pC 6-1.7-t2-16) fi1666N 6HU�{ti� Rd�!?g(?
Name of icant (�rst, middle, last) it,) / O U'' '
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Address (street arrd numtbe , ate, ZIP c e) �, / / Coun
0 d. CL� lC 2 //.3.5 � �
Applicant ( dces I dces not ) own properiy with another irWividual(s) besides spouse andlor anoNer ve[e2n.
This applicalion is made for the purpose of obtaining S�/ i` �� deduction from the assessed valuaLon of the fdlowing described taxable
property forthe year20_
Taxing 'strict (yrty�q , township) Is the property in questlon: Parcel or K number 'L
Q�/-�p ^% Real Property ❑ Mobile Home (IC 6�1.7-7) � ���,,,% �O/— ��0. O 7 Qa1
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A L7 AppGcant �vas a member of tlre U.S. Nmed Forces fa at leas[ 90 days (rat necessardy dunrg wai 6me�
B. O ava�m �s n«,o�dy d5d�aryed.
C. � Ap�nnt is: ❑ Tofally disaded; w ..
❑ N leasi age 62 with at least 10% disaltiti[y
D. ❑ AppfiranYs disadTity is evidenced by. ❑ Certifirate d efigibdiry from the Indiana Departrnent of Veterans Affa"vs;
❑ Pension terOfitate:
❑ Award of mmpensalion Gom Veterans Admv�istration or Department of Defense; a �
❑ Veterdre Admirtistra0on Form 20.5455'Tax Abatemerrt CeJtifinte'
E. ❑� The assessed vahiatim (at 100%) of the property for which ihe deduction is daimed (may rrot exceed 5773.000) 5
F. � A{�plicant is the surviving spouse of an individual who wouW have qualified fa the deducrion under tlus section when he or she vras alive.
(A'ge o/deceased veferan on date W deaUr )
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A 0 Applicant was a member of the U.S. Artned Fwces during any of its wars.
B. � Applicani was horrorably discharged.
C. 0 Applicanl has a service-connected disability o( at least 10%
D. ❑ Applirant's disability is evidenced by: ❑ Certficate of eligibility from ihe Indiana Departrnent of Veterans Aflairs:
❑ Pension certificate;
❑ Award of compensatim 6om Vete�ans AdminisVation or Deparlment of Defense; or
❑ Veterans Administralion Fortn 20-5455'Tax Abatemenl Certificate"
E. � Applicant is Ne surviving spouse of an indiviA���l whn wrn�l�i havn qualfied tor the deduction under Nis section when he or she was alive.
(Age o! deceased veteran on date o1 death )
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�Appiicanl a a veterari of Wald War I.
AppC�carri's disa�ty is evidenced by ❑ Letler from Veterans AdrtuniWation a Departrm.nt W Defense; or
❑ Disdarge dowmer�
C. ❑ The asscssed valuation (at 100°,6) ot the property fa whidi the deduction is daimed (may nw exceed 5163,000) S - --
D. � The property is the ap�cdnYs pruidpal residence. �
E- ❑ The apd'xant amed tlre property (w was buyirx� d imdercaN-aG) for at leas[ me year befae the date of ihis app6cation. • .
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