Veterans_Hatleyi
Form Number 12A - Revised 1977
Prescribed bR�+-S�t�te Board of Tax Commissioners T
: FILED`:
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY '
� JUN 1 3 1991
and Apnlication for Deduction From the
Assessed Valuation of Taxable Prooerty
�_ *** Qualifications On BacY. *** �""" A�DITO���
STATE OF INDIAVA ��lr� COUNTY, SS: '�
(Name) ���A'� `� ��"���� , beina duly sworn on oath says
that (s)he is � years of age;�)he resides at �" v" � J�I
��,�0 p�( �Qp in County, Indiana; that (s)he
Check One: was a afember 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�:
Pension Certificate or �
��ward of Compensation or
eterans 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 of 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 $L-�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19G� ,
to W�t:
TAXING DISTRICT
O/�"00�6f� �
LEGAL DESCRIPTION OR KEY NOMBEr -� pL - �I V
That, in addition to the a�bov -t of $ deduction applied
for in this County, (s)he has or�ds to apply•for $� deduction
in County, ��yy��n�--���, Taxing District.
`q/�� �, % /
�G O��il�-vCi! �!/ i aY �-
(Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this �
day of , 19�. +�.
� 1vt�vt s� Gm ���. `r
Auditor
o -�