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Form Number 12A - Revised 1985
Prescribed by State Board of Tax Commissioners
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� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONN ED ABIL l''�����
'` and Application for Deduction F om t� ���.30 ���-
�� Assessed Valuation of Taxable P�operty '
*** Qualificat�ions On BacY. *** �'y,,.�
STATE OF INDIANA � 0'�Sx� COUNTY, ss: AUDITO-R-O���
(Name) �n z�CCo t, ��� c_ .ti.��� :�eing duly sworn on oath says
�hat (s)he is 5� years of age; that (s)he resides at �
��� �� . �-�5a � aso s
in � County, Indianna; t'h1a (s)he
Check One: was a Member of the U. . rme y 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:
O
Pension Certificate or
Award of Compensation or . ��� ��-� 1
_�p 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 o£ the ar.me.d_£n ces an/I��jags-�
IJ�,
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 obtaining
�3� �-�fo.
(not to exceed four thousand dollars) deduction from the asse sed valu-
ation of the following described taxable property for the year 19_,
to wit:
TAXING DISTRICT � ,�.-,ti,
LEGAL DESCRIPTION OR KEY NUMBER Qo a., V��� c•,�n
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.
� (Ap � nt/G�� .+
� Subscribed and sworn to before me, and disability verified this ��
=� day of , 19 l5
� ,�� � � _ �`--jrC� , � „�r�° ,
Auditor —�