Veterans_Oneal (3)�orm Number 12A - Revised 1977
-.Prescribed by State Board of Tax Commissio�ners ��'1
:= �,� �c��� \ �,;�
' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY .�i ( �\
t ^
and Application for Deduction From the �` 'h
t Assessed Valuation of Taxable Prooerty �i J
**• ¢
��� , being duly sworn on oath says
� that (s)he is S� years of age;,,.that (s)he resides at ,¢p-yy�.n�„/Qa�
in /-wl.�ar+� County, India�na; that (s)he
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
wno served dur�ing any of its wars
and who has been honorably discharged there£rom and has a service-
connected disability of ten percent (10 per .�3� d is '
entitled to this deduction as.evidenced by.-:�� ��� .
Pension Certificate or � � �
Award of Compensation or �i��{R � I�p�
�_ Veterans Administration Form 20-5455 "Tax Abatement Certificate"� or
` LettPr statement of ten percent disaY��l,�t o�r m e fr�om the
De artment of the Defense Disabili�e � � rd�of the
appropriate branch of the armed forces,UDITOR . •
�exhibited to the County Auditor. � .
�9�G-_ y�oa
IC 6-1. 1-12-13 and 6-1.'1-12-15 3ooa
. � �Cj�y_.
Tkiat this application is made for the purpose of obt3ining $�
(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 ��--�-�-r -� -
That, in addition to the above amount��of $ deduction applied
for in this County, (s)he has or intends. to apply for $ deduction
in • County, Taxing District.
X��Q ��� �
(Applicant/Guardian) �
�� Subscribed and sworn�to before me, and disability verified this 3
d a y o f `%�% (,t/L[.%l. � � � . 19l� z . • � - � , -
,7�Go C'�-�-�F�-- ;
Auditor
�