Veterans_Wiseman� Form Number 12A - Revised 1977 ���—�I�� ("�� ��
Pr.escr-ined by State Bo'ard of Tax Commissioners �,� �
s` � � �/
' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED
�� ��_�
**x Qualifications On BacY, *** /[��.� �
STATE OF INDIANA � Q,J��jV\ COUNTY,'
(Name) , � �,�.(, �y�'yQ�/�.�, being duly sworn on oath says
that (s)he is �� years of age; that (s)he resides at ����A/yyl��
in �� �}Q�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
� and who has been honorably discharged therefrom and has a service-
i connected disability of ten percent (10 percent) or more� and is
entitled to this deduction as evidenced by:
I
� 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. 1-12-15 �/ o� �`� d�D
./9b'/�/ 3oeo
That this application is made for the purpose of obtaining $�
I
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19��
to wit: ,
( TAXING DISTRICT
�G[� ryn_S�P� OR KEY NUMBER �,� ��� i��Q� -
�I. ��Y �� �L
That, in addition to the above amount of $� deduction applied
APR 15 i°8�
� for in this County, (s)he has or intends to apply for $ deduction
��n�• � County, Taxing District.
' �-\ 1 I V . .
��QO .tnontir,� ,
(Applican /Guardian) �
�.� Subsczibed and sworn to before me, and disability verified this LS �`
day of ���� , 19�
� �� n e �
i Auditor