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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fartn 72662 (R9 / 5-OB)
Prescribed by Ihe Department of Lacaf Govemment Fnance
�RUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Section ll.)
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION.
❑ I Totally disabled veteren (or ve(eran at least age 62 with at least 10% disabilify) or surviving spouse - Not to exceed 572,480
Complete sec[ions I, V and VI. (IC 6-1.1-12-14)
❑ II Partially service-connected disabled veteran OR surviving spouse - Not to exceed 524,960
Complete seuions II, V and VL (IC 6-t.t-12-73)
❑ III Worid War I Veteran - Not to exceed 578.720
Complete sections III, V and VL QC 6-7.7-72-77.a)
❑ IV Surviving spouse of Wodd War I Veteran - Not to exceed 518.720
Complete sectlons IV, V, and VI. (IC 6-7.1-72-16)
Name of i nt �rs1, middle, 1 t)
Addmss (street and number, ' , stafe ZIP code � ^ , (� � � ` � � . ' , : Co y�/��� U-r� �\
\ii�W�.Ci• � WI%1 0 ✓ W�!V,v
Applicant ( dces I does not ) own property with another individual(s) besides spouse and/or another veteran.
This applica5on is made for the purpose of obtaining S� U V dedudon from the assessed valuation of.the.following desuibed,tazable
ProP�Y for the year 20_I � � � �y�0�' �. —
. Tazing District (cily, towq township) Is the perty in quesqoo: Parcei or Key number 1
eal Property ❑ Mobile Home (IC 61.1-7) � `
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'�!� APP6cant �ras a member of tlie U.S. Armed Forces fa at least 90 days (rwt necessardy dunrg war �ne�
B. ❑ %ppGcant v� horarably dis�harged. �� �%�� ��
�C: ❑ APP�rarrt is: ❑ Tdally disaded: a w�p`�/W .
� ❑ At least age 62 wiUi at least 10%disabtlity �n��p,���� �A
D. � Appfrcant's disabLty is evidesced by. ❑ Crltificate N efgbaity from tne Indiana Departrnenl of Veterans Aftairs: AfMr�i.7
❑ Pension cerGfi�te: .
❑ Axard M canpensation (rpn Veterans Admmistralim or Departrnent of Defense: w �
❑ Veterara Administra�on Form 20.5455'Tax AbatemeM Cefificate"
E. ❑ The assessed valuatlm (at t00Yo) W the property for whKh ihe deduction is daimed (may not exceed 5773.000) S
F. ❑ Applrcant is tl�e surviw�g spouse of an irWividual who would have qualified tw the deduc�on under this secuon when he or she v.as alive.
(Age o/deceased veteran on date d deaM )
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A❑ Applipnt was a member of the U.S. Artned Fwces during any of its wars.
B. � Applicant was horrorably discharged.
C. ❑ Applitant ha5 a service-tonnetted disabiiity of at leasl 10%
D. 0 ApplicanYs disabiGry is evidenced by: ❑ Certificate ot eligibiliry from ihe Indfana Departrnent of Veterans Affairs:
❑ Pension certificate;
❑ Award of compensation from Veterans AdminisVation or Department of Defense; a
❑ Veterans AdministraGon Form 20.5455'Tax Abatement Certifiwte'
E. ❑ Applicant is the surviving spouse of an individual whn wnuld ha�e qualfied for the deduction under Nis secGon when he or she was alive. �
(Age ofdeceased veteran on date o7death ) --
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�r] Applicarri is a veferan of WaM War I.
] Appiicarrt's disab3iry is evidenced by: ❑ Letter (ran Veterans Adrtun'�s4ation a DepartmeM of Defense; or
❑ Oadiarge dowments
C. � The asse.ued raluation (at 100%) W Me property for whidi the deduc0on is daimed (may nU exceed S 763,000) 5
D. O The properry is the appGcarA's proidpal residence.
� E. ❑ The appfipnt ovmed tlre popeity (a was buyrng it under camad) for at least me year before the date of ths applicauori ..
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