Veterans_WilkisonForm Number 12A - Revised 19-�7 �O/—�O//�/ �rou�hj 11¢ �
„LPrescribed by State Board of Tax CommissYG•nErrsO���a � -_PnQ ¢rS '��"O-^`
C�� / `r
V R �» io-ai-o�
. VETERANS, OR TNEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY /�
and application for Deduction From the � v.
� Assessed Valuation of Taxable Property '/�/ '
*** Qualifications On Back ***
STATE OF INDIANA ��jy�ryL� COUNTY,
(Ciame) ��µ.C?� p(, //j/��jQf�j-yL�being duly sworn on oath says
that (s)he is �years of age; that (s� res�� , ��./y�� �
b � Couh�Indiana; that "(s)he
Check One: was a Member 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
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. 1-12-13 and 6-1. 1-12-15 /� _
That this application is made for the purpose of obtaini/n� ��
(not to exceed two thousand-dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 ��1
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
�
- Thqa�t�, i a"�to the above amount of $ deduction applied
for irt'f�h� ,(s)he has or intends to apply for $ deduction
�a �
in a��Z,� »�" County, Taxing District.
i�+a (� r
X V • � W �lI��AIbV\
��o.p1,��R � (Applicant/Guardian�
� SubscrPbed and sworn to before me, and disability verified this �r y�
day of , 19 O �
�
Auditor