Veterans_Wilson�- Form Number 12A - Revised 19�!!
Prescribed by State Board of Tax Commissioners
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY �.0
�,�\ and Apnlication for Deduction From the �\ ��
' 1 �
Assessed Valuation of Taxable Property
� **• Qu lifications On Bac!: ***
STA .. OF INDIANA �a(,/� COUNTY, /
� (Name) ����) , being duly sworn oath says
that (s)he s�o� years of ag �• that (s)he resides at �F-LrrXJ
� 1DL� in County, Indiana; that (s)h�e
IG 7 P6-
Check ne: �� �as a,fember 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: /� I'
Pension Certificate or ' 1_� •_ � q
Award of Compensation or
�veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
� 1 Department of the Defense Disability Retirement Board of the
��� � appropriate branch of the armed forces
�exhibited to the County Auditor.
q�G- �ood
IC 6-1. 1-12-13 and 6=1. 1-12-15
/9�y_ 3 0 00
That this application is made for the purpose of ob�aining $�--
(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 DI�SsTRICT �
LEGAL �E3C��� KEY NVM R - ' f�
`ffi
Tha n addition to the above amount of $
tMAf� � 5 �o�� —
for th's County, (s)he has or intends to apply
� o� �
for $ deduction
in �� County, Taxing District.
x GV�r, �
.� (Applicant/Guardian)
,�) Subscribed and sworn to before me, and disability verified this ��
��ay of y%�4it_-.�C� , 19�
.�� _ �'',�..�-�-��C
Auditor
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