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
