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Form Number 12A - Revised 1977
_Pre.scribed by State Board of Tax Commissioners � �" \
� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY XX
1' `
and Application for Deduction From the �
� Assessed Valuation o� Taxable Property �%1
� **' Qua�ifications On Bac'.: *** � O
n e
STATE OF INDIANA ,��l.Xl�t�' ,yQ, COUNTY, SS:
(Name) J�,p,nVCt4 , being duly sworn on oath says
thatj (s)he is�"�1 years of age; that (s)he resides at ,Q.� ��,�(po�
�7�ytA in „%�� County, Indiana; that (s)he
Check One: was a Nember 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 o£ 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 Abateme t' t' or
Letter statement of ten percent disability or more from t e
Department of the Defense Disability Retirement Bpa,rd if1gt,Ja,e
appropriate branch of the armed forces 1�9/-1T yU
�exhibited to the County Auditor. aj�.���+ YXt�trS
AUDITOR a
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $� g�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 'IC�,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER ,��, ��/�I �w/� dI- �`9 ��..Q,� I���
That, in addition to the above amount of $ Lf'� deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in ,.i� CountY, \ �� Taxing District.
x OL�n.� �'�z�C�
(Appiicant/Guardian)
Subscribed and sworn to before me,
� day of , 19 lV,
and disability verified this 1
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auaitor