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�Form Number 12A -TRevised 1977 � ��
Prescribed by State Board of Tax Commissioners �� YG�
- .. VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
_ �
and Application for Deduction From the
� Assessed Valuation of Taxable Property � 3
*** Qualifications On BacY. ***
STATE, O INDIANA _���� . COUNTY, �
1� �
(Name � � , being duly sworn on oath says
�
�hat (s)he is years o� age; that (s)he resides at
F.,Q,/ ��G. Bh_o-.-r.�LSI _��.gp�� County, Indi a; that (s)he
Check One: `-'� was a Member of the U.S. Armed Forces durinq 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
L
�exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15 �� �� �� ��
/9 � S/ - 3 Do a
That this application is made for the purpose of obtaining $`�.�
(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
LEGAL DESCRIPTION OR KEY" NUMBER ��j f% �/�f�p„r
in t on to the above amount of $ deduction applied
�'��� j � i
for in this County; (s)he has or intends to apply for $ deduction "��---
MpR 181982
in County, Taxing District.
�� 0. X �, v�° ��
AUD170R (Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this �
day of %�%J 4i�{� , 19�a •
. N • o • ��.,.-�-e.
Auditor