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APRLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Farm 12662 (RB / 4-04)
Prescnbetl by Ihe Department of Local Government Finance
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INSTRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More lhan one box may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduction under Section ll.)
. G DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION. �� � � �
❑ 1 Totally disabled veteran (or veterdn at least age 62 with at least 70% disabtiity) s g u e ot o x 572.480
Complete sections I, V and VI. (IC 6-1.1-12-14)
❑ II Partially service-connecied disabled veteran OR surviving spouse - Not to exceed 524,96Q L 2 2�� �
Complete sec6ons II, V and VI. (IC 6-7.1-12-13) ��
❑ Iil World War I Veteran - Not to exceed 518,720
Complete sections III, V and VI. (IC 6-1.1-12-17.4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed S�8,720
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(:IRRf1N COIINTY AUDITOR
Complete sections N, V, and VI. (IC 61.1-12-16)
Name ,
state, ZIP code County
Applicant ( does / does not ) ovm property with another individual(s) besides spouse and/or another veteren.
This appliwtion is made for the purpose of obtaining S deduction 6om the assessed valuaUon of Ne following desaibed taxabte
property for the year 20_
Taxir� Districi (city, town, township) Is the property in question: Parcel or Key nvmber
�.� ❑ Real Property ❑ Mobile Home QC 6-1.1-7) �(o -� d— � a, 3 DD — D D D, � Y 7"� �
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� P.pplicant was a member of the U.S. Mmed Forces (a at least 90 days (rwt necessanly dunng war 6me).
B. ❑ AppGcant was honorably discharged.
C. ❑ Applicant is: ❑ Totaly disabled; or
❑ At least age 62 with at least 10°h disability
D. � ApplinnYs?sabiliry is evidenced by. ❑ Certifipte of eligibility from the Indiana Department of Veterans Afiairs;
❑ Pension certificate: � '
❑ Award of compensation from Veterans Administralim or Department o( Defense; or
❑ Veterans Administratlon Form 20.5455'fax Abatement Certificate'
E. ❑ The assessed valuation (at 700%) of the property for which the deduction is daimed (may rwt exceed 5713,000) 5
F. � Applicant is the surriving spouse of an individual who would have qualified for Ne deduction urMer this seUion when he or she was alive.
(Age o(deceased veteran on date o7deafh )
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A. ❑ Applicant was a member of Ne U.S. Artned Forces dunng any of its wars.
8. ❑ qpplicant was honorably discharged.
C. ��pplicant has a service-connected disability oi at least 10%
D. � ApplicanCs disability is evidenced by: ❑ Certificate of eligibility from lhe Indiana Department of Veterans ARairs;
❑ Pension certi(cate;
❑ Award of compensation irom Veterans AdminiSVation or Department of Defense; or
❑ Veterans Administration Fortn 20-5455'Tax Abatement Certificate'
E. � Applicant is the surviving spouse o( an individual who would have qualified for ihe deduction under this secUon when he or she was aiive.
(Age o/ deceased vete�an on date of death )
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A � Applicant is a veteran of World War I.
� ApplipnYs disabiGty is evidenced by: ❑ Letter (rom Veterans Administration or Department of Detense; w
❑ Discharge documents
C. � The assessed valuaGon (at t00qo) of the pmperty for which the deduction is daimed (maynot exceed 5163,000)� S
D. ❑ The propeAy is the appliqnfs principa� residence. .
E. � The applirant owned the property (or was buyirg d under conhaIX) for at least one year be(we the date of ihis apptication.
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