Veterans_RichesonForm Number 12 - Revised 1977
Prescribeti by State Board of Tax Commissioners
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VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILITY
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and Application for Deduction From the ^ O
Assessed Valuation of Taxable Property I'� 1
*** ualifications on Back **• d�
STATE OF INDIANA 'w COUNTY, SS:
(Name) ��QQ�A �,,� fS�f�a.ntYV� , being duly sworn on oath says
that (s)he is � years of age; that (s)he resides at l�-ULf�+L�
in R� �(��(�, County, India�,��e
Check One: was a nurse
was a Member of the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
and who served for ni y(90) days or more, not necessarily during the
time of war, and has been honorably discharged therefrom and has a total
disability 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 Total Disabliity from the Department of the
Defense
� Disability Retirement Board or the appropriate branch of the
armed forces
exhibited to the County Auditor. O I���� r p�J
IC 6-1. 1-12-14 and 6-1. 1-12-15 U J
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That this application is made for the purpose of obtaining �
(not to exceed one thousand dollars) deduction from the assessed valua-
tion of the following described taxable property fpr the year 19�, to
wit: n ��
TAXING DZSTRICT (CITY, TOWN, TOWNSHIP) ��� Ca�
LEGAL DESCRIPTION OR KEY NUMBER IC'i 0���.
That, in addition to the. above amount of $ deduction applied
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for in this Coupt�,�sh�he has or intends to apply for $ deduction
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in Coun Taxing District and that
the total assessed �� �ue��"'� all his/her taxable property as shown by the
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tax'duplicates�o-ftj �1 counties in which they own pro rty is S
.;r���r �( 0 9 o Q�. �-v .�-�
_ � _ (Applicant/Guardian)
Subscribed and sworn to before me, and disability verified this �
� day of , 19�. �
� ,� C,� ��, �R �
Auditor