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Veterans_Cline� orm Number 12A - Revised 197! p/-�� Prescribed by State Board of Tax Commissioners �// �� �� . "ss, F�� � VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY �� �j7�� =o� and Application for Deduction From the ��� i� � 1- Assessed Valuation of Taxable Prooerty _,^ � �; **' Quali=ications On BacY. *** �-���'j STATE OF INDIANA �}.a,� COUNTY, SS: ��I (Name) Q,�,p_,d ���„_q� , being duly sworn on oath says - that (s)he is � yea s of age; that (s)he resides , �,� �in� �a�}�S.% County, Indiana; that (s)he ( �a" 1 � �y-/V Check One: �/ was a Pfember 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 0 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 oi 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 two 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 That, in addition to the above amount of $�_ deduction applied for in this County, (s)he has or intends to apply for $��� deduction _L�`�' � , .� in County, -�p-.�"{' Taxing District. X W.Sl.�te ��l�s�`C �^'� LX t� l (Applicant ua�� f � Subscribed and sworn to before me, and.disability ver' day of , 19� . FEB 14 1990 � pa�to� ITO�s