Veterans_Rowe�
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� Form Number 12A - Revised 1985 ��" �•
Presctibed by State Board of Tax Commissioners yy � }
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABI�����'
i
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and Application for Deduction From the
Assessed Valuat�ion of Taxable Property
**�m,ualifications On BacY. ***
STATF nc 7NDZANA
COUNTY,
SEP 13 1999
S S : �BSON C;pUt.TY AUDITOR
(Name) � _ � being duly sworn on oath says
at ( Lhe is � years o age; that (s)he resides at �� �/ '✓L oV�
� `
in County, Indiana; 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
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 Abatement Certificate" or
Letter statement o£ 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.
IC 6-1. 1-12-13 and 6-1. 1'-12-15
That this application is made for the purpose of obtaining $ O O�
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19_ ,
to wit:
TAXING DISTRICT
�
LEGAL DESCRIPTION OR KEY NUMBER��_�_�_ �� /� �—'O�O
That, in addition to the above amount of Q Q Q deduction applied
for i is County, (s)he has or intends to apply for $ deduction
in County, T ing District.
X
( ppYi ant/Guardia ':
� Subscribed a sworn to before me, and disability verified this �
� 4 — i
day of �` , 19�.
��� (�/ . �/l�.� ���
Auditor