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Form Number 12A - Revised 1977 .
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
- �,- � I -�
and Application for Deduction From the `\'
Assessed Valuation of Taxable Prooerty ,�� /l
*** Quali:ications On BacY, *** C
STATE OF INDIANA ��Q/t/� COUNTY, SS:
(Name'j �,�� Q` I�JCJ'IJ�kJ.�- , being duly sworn on oath says
that (s)he is � years of age; that (s)he resides at ��' .tA/YYIYR.-Ci
�l ��f�+ �q5 in _-�,Q�y� County, Indiana; that (s)he
Check OneO ��as a Member of the U.S. Armed Forces during any of
its wars
or *h� �a^�° f a member of the U.S. Arned Forces
who served during any of its wars
and has been honorably discharged therefrom and has a service-
connect 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. .
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ic s-i. i-i2-is �,a s-i. i-i2-i�
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Tha�A�h�� �lication is made for the purpose, f obtaining $�'�'
`�
(no�tq ceed wo,-thousand dollars) deduction from the assessed valu-
e0 �
ation ��jpkj{�2f 1 owing described taxable property for the year 19�
to wit:
TAXING DISTRICT ef�Q�JYy�Q�� � ��� ��,1
LEGAL DESCRIPTION OR KEY NUMBER �* ��j`,�QJ
That, in addition to the above amount of $ deduction apolied
for in this County, (s)he has or intends to apply for $ deduction
in
County, Taxing District.
X `Z�l� .c.�,r,�.�,� �. � �-�,�.e�
(Applicant/ uardian)
�`
Subscribed and sworn to before me, and disability verified this ,3(�
day of ��\Q� , 19�ds
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