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;� rm Number 12A - Revised 19i7 ��O —��
�.'Prescribed by State Board of Tax Commissioners
c: - _ , -.
°' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED D�������
and Application for Deduction From the
�� Assessed Valuation of Taxable Property SEP 1 8199?
�** Qu lifications On Bacy ***
STATE OF INDIAVA OUNTY, S�q�tRJ��
au���, a�y
(Name) � , being duly swor on oath says
that (s)he is yeazs o` age; that (s)he resides at
in County, Indiana; that (s)he
Check One: was a Member of the U.S. Armed Forces during any oi
���� 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 �
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 of the armed forces
�exhibited to the County Auditor,
IC 6-1. i-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 o£,$ deduction applied
for in this County, (s)he has or intends o apply for $' deduction
in ��� County, �MANmX� Taxing District.
0
X
lic/a�j�.]Guardian)
Subscribed d sworn to before me, and disabil y verified this ���"
�
day of • , 19�. „
p . `i��,,�,�.� ; _
Auditor �—