Veterans_Lanham"' APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, �����
/� � WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
� Stata Form 12fi62 (R77 / 10-0B)
S Presaibed by lhe DepaRmerit of loml Gwemment Fi�nce
NOV 16 2011
INSiRUCT10NS: Please check appropriate box(es) peRainim� to tax deduc6on. (More than one box may be cherJred; hoiveve�, a surviving
spouse wiro receives a deduction under Section IV may not receive a deduction under SecGor�.J�.N�
FILING DATES:
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT.
MOBILE HOMES (IC Cr1.1-7) OR MANUFACTURED HOMES NOTASSESSED AS REAL PROPERTY: DURI6J8S� AA�L�/TEY(4L�GUbARHS
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTION.
� I Tofaiy disaWed veteran (o� veteran af feasl age 62 wifh af least f0% dise6ility) or surv'rving spouse - Not to rxceed 5�2,480
Complete sections I, V and VI. QC Et.b12-14)
� II Partialry service-connected disabled vete2n OR survrving spouse - Not to exceed 524,960
Complete sectbns II, V and VL (IC G7.1-12-13)
❑ III Worid War I Veteran - Not to exceed 5'18,720
Complete sections III, V and VI. QC 61.1-72-17.4)
❑ N Surviving spouse of Wwld War I Vetaran - Noi to exceed 518.720
Complete sections N, V, and Vi. QC 6-1.1-12-16)
Name of app � nt (first, mMdle /ast) Date of birth�(monN, day, ysa�
� Lan �a M
Addr�s5 (,s6eet and num r�ty, state, arMZIP code) 5 ` County
�� J� 6 /. iT�
Applirant Qdces Q1oes not ) awn property with anoNer individual(s) besides spouse andfor another ve eran.
This applicatbn is made for the purpose of obtaining S��I I�� deduction from t�e assessed valuation of the fdbwing described taxable
property fw the year 20_
;.�cing DisMct (city, town, township) Is t�e property in question: Parcel or Key number
� Real Property ❑ Mobile Home (IC 6-1.1-7) z -o -ZCn c� S'�y -
• � •• i. _
A � App&ant xas a member of ihe U.S. Artned fwces for at least 90 days (rrot ne�ssany du�g war6me).
B. ❑ ApP6cant was honorady dischaf9ed.
C. � App6caM is: ❑ TotaOy d�sabled: or
❑ N least age 62 with at I�si 10% disabiGty
D. Q AppficanYs d�saWLry a e�ridenced by: ❑ Certifrate of eligibiGry from the Indiana Departnrent d Veterans Aftairs;
❑ Pension certificate;
❑ Award of compensatim from Veterans AdminisVatim or DepartmeM o( Defense; or
❑ Vete2ns Admin'stration Form 265455 Tax Abatement CeAifipte'
E. ❑ me assessm �ran,ason (at tarw) or the aoaertv ror w�va, the dern,dio� rs dair�rea (may rrot erceed S74$ ib�j s
F. ❑ AppGrani is �he surrtvin�j spouse of an uidividual who wwld have qualified fw Me dedudion under ihis sectio� wha� he or she was alive.
(Age d deceased veferen on tlate d deeth )
_ € • �
0.�Applicant was a member of the U.S. Artned Forces during any of its wars.
B. Applicant was honwabty discharged.
C. �] Applinnt has a servke connected disabiliry of at least 10°/
D. ❑ AppGcanYs disabiliry is e�ridenced by ❑ Certificate ot eligibiliry from the Indiana Department of Veterans Aftairs;
❑ Pension certificate;
� Awafd of compensation from Veterans Adminishatbn w Department of Defervse; w
❑ Veterans Administration Form 20-5455 "Tax Abatement Certificate
E. ❑ Apd�+t �s the surviving spouse ot an indhridual who would have quaified for the deduaion under Nis seGion vfien he w she vras alive.
(Age o/ Ceceased veteran m date o/ death )
• °
�❑App&ant is a vetsan of World War I.
�1. ❑App5rarrt's service "s evidenced by ❑ Letter from Veterans Adrtdnatration or Deparhnent d Defense; w
❑ Discharge dacuments
c. ❑ me assessed van,aeon (at to09c) of a,e procenr ror wka, me dedudfon s aaimed (rney „ot exoeed s2os,soo) s
D. 0 The pmpefty is ihe appfiranCs pruidpal residence.
E. QThe app5<ant ormed the pmpeAy (or �ras 6uy"ing if �r oontrac� tor al leasl one year beFOre the date of this app6cation.
t� • � • �
RECEIPT FOR APPLICATION FOR TAX DEDUCTION
FOR DISABLED VETERAN, WWI VETERAN OR SURVIVING SPOUSE OF CERTAIN VETERANS
• I certi(y that the applicant filed on this date an application for the following deductions described on State Form 12662:
❑ SECTION I ❑ SECTION II ❑ SECTION III ❑ SECTION IV
Name of applirant (first, middle, last) Name of auditor
Parcel or Key number Date (month, day, yea�