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_ Form Number 12A - Revised 19!! �� ��
' 'Prescribed by State Board of Tax Commissioners �
� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABIL� X�� �
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and Application for Deduction From the� j� }�j�
Assessed Valuation o: Taxable Proper�y A���� �
�
. *** Qualifications On BacY, *** �'
/�// pCT �'�95�
STATE OF INDnZAVA (�- COUNTY, SS:
(Name) ___y�� � �eing duiYy�ns�iorn�fin'�ath says
auo� � oK
that (s)he i years o� age; that (s)he resides at (��d�
in �//,3.i�7[ County, Indiana; that (s)he
Check One :� was a �tember 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
an�� V (n/ TLj��
who has be� 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
v 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 Eoard of the
appropriate branch of the armed forces
�exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-1�
That this application is made for the purpose of obtaining $�
(not to exceed two thousand dollars) deduction from the assessed valu-
0
ation of the following described taxable property for the year 19�
to wit: �� � �
TAXING DISTRICT �p i,.
LEGAL DESCRIPTION OR KEY NUMBER
That, in�addition to the above amount of $�_ deduction applied
for in this County, (s)he has or intends to apply for $�' deduction
in ��1,�/�ja' County, ��� Taxing District.
� �� � ��
(Appl ant/Guardian)
Subscribed and sworn to before me, and disability verified this �p
��1day of ��� , 1�. �
��icc. 7//U /i �O .
uditor
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