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Form Number 12A - Reviase;i 1977 �� -� M��-� ��
Prescribed by State Board of Tax Commissioners�
VETERANS, OR THEIR WIDOWS. STATEMENT OF SERVICE-CONNECTED DISABILITY
and Applitation for Deduction From the ��^�
Assessed Valuation o: Taxable Prooerty
*** Qualifications On Back ***
STATE OF ZNDIANA ��� COUNTY, S5: � �
(Name) �, , being duly sworn on oath says
that (s)he is `� years of age; tha (s)he resides at ��r--f'�(i��/"i-r'-.
� 2 � 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 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.
IC 6-1. 1-12-13 and 6-1. 1-12-1�
�q��" �fot'a
/QqA_ _ �pea
�iY
That this application is made for the purpose of obtaining $o�
(not to exceed two thousand dollars) deduction from the assessed valv-
ation of the following described taxable property for the year 19 �Z
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ deducti-on=appli-ed
for in.this County, (s)he has or intends to apply for $ deduction
in � � Taxing District.
.%oe� Q
(A plicant/Guardian)
�p3 � 198Z _ '
Subscribed and sworn to �e'fore me, and disability verified this
.. day of \.� .� lvv_ .S,ey� 7
-• vCF>w
p�JpITOR � .
Auditor