HomeMy WebLinkAboutVeterans_BealForm Number. 12A - Revised 19-l7 (ll_/�� �`�`�
Prescribed by State Board of Tax Commissioners �
,, ^ VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISAB7LITY
�� s-3
and Application for Deduction From the
Assessed Valuation of Taxable Property
*** Qualifications On BacY. ***
STA'�E OF INDIANA ��j���� COUNTY, SS :
\
(Name) `6��rU r/vr'-cr-- �� , being duly sworn on oath says
that (s)he is � years o: age; that (s)he r_esid.es at
/ , 1
�� e%Y�[.c., in ��y�/ County, Indi a; that (s)he
Check One: was a� mb'er of the U.S. Armed Forces during any of
/ its wars
v 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 c�
Veterans Administration Form 20-5455 "Tax Abate'me� �r�'9f ate" or
Letter statement of ten percent disability or �r rom the
Department of the Defense Disability Retirement Bo;r��d'� the
�_ appropriate branch of the armed forces (�P{i -
exhibited to the County Auditor. Y" �� �,
d°6 P��gCe - �B9
IC 6-1. 1-12-13 and 6-1. 1-12-15 g Qy�
O o O
That this application is made for the purpose of obtain�ng
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 �-S
to wit:
TAXING DISTRICT
LEGAL DESCRIPTZO
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $_ deduction
in
County, Taxing District.
X "// �iH-L��i � ��X�W
(Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this �
` day of � � � . 19 �� �'
Auditor