Veterans_DeutschForm Number 12a - Revisec 1977 �J�7-���aJ �
Prescribed by Stace Board of Tax Conmissioners i, - — -
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED D�SABFL-I-T-Y�.��
• !i
j_ anc Aoplicatioa for Deduction From the l�__ "�
� � Assessed Valuation o: Taxable Pro�erty � �-I �
*** Qualifications On Bac:: *** �
STATD_ OF iVDIAVA ��y.7�/r� COUVTY, SS. �lM� �
(Name) J�r�LM�`iQl� a � , neinc duly sworn on Oath says
i
that (s)he is _� years of age; that (s)he resides at f�J{ �
� � � � County, Zndiana; 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
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�
and who has been honorably discharged therefrom and has a service-
connected disability of ten percent (10 percent) or more and is
entitled to th`_s deduction as evidenced by;
�Pension Certificate or a�y-j3"aY-l00^00�; (�s(p-00�
Award of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
Deoartment of the Defense Disability Retirement Board of the
appropriate branch of the armed forces
exhibited to the County Auditor.
� �+ . I ) f �l �lo �i D � °
���a �� � IC 6-1. 1-12•13 and 6-1. 1- 2-1- ��g-�! _ 3 p� a
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That �1}�i,s apgl�,cation is made for the purpose of obtaining $_ ��,�
,.. .. � �--�
(not •,/�o� � cer ed two•� thl usand dollars) deduction from the assessed valu-
ISC� �y
ation of tht�.}CBoQg ing described taxable pro_pe'rt� h�r 19 b�
to wit:
TAXING DISTRICT
►
LEGAL DESCRIPTION OR KEY NUMBER `LQ ��, 1°� �pQ,
That, in addition to the above amount of $ deduction aoolied
for in this County, (s)he has or intends to aooly for $ deduction
in
County, Taxing District.
� X /, �-�4.rrlbt- C. . �
(Ap licant/Guardian)
'� Subscribed and sworn to before me,
day o: � �� , 19�`
�
,
and disability verified this'•��
�-� ��,�.��-cn.,�J
Auaitor