Veterans_Pickens�
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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WWI VETERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS
State Fwm 12662 (R9 / 5-06)
Prescnbed by Ihe Department of Local Govemment Finance
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�RUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one 6ox may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduction under Section II.J
FILING DATES: ��
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE11 OF THE YEAR THE DEDUCTION IS yu /tPFLYir
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHid�a'tHEiINDIVID�V S TO
OBTAIN THE DEDUCTION. d- � � �a,`y�.,'/
❑ I Totally disabled veteran (or veteran atleast age 62 with a( least 70% disa6iliry) or surviving spouse - Not to exceed 512�9
Complete sections I, V and VI. pC 6-1.1-72-14) SE� L
❑ II Partially service-connecied disabled veteran OR surviving spouse - Not to ezceed 524,960 y Z�09
Complete sections 11, V and VI. (IC 6-7.1-12-13)
❑ III World War I Veteran - Not to ezceed 578.720
Complete sections tll, V and VI. QC 6-1.7-72-77.4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 518,720
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GIBSON CpUN7y AUDITOP,
Complete sections IV, V, and VI. (IC E1.7-12-16)
Name of apDli nt first, m dl st)
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Add2ss st arM n ber. �. sta[e, ZIP e) " /_ /_ Coun
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Applicant ( dces I does not ) own pmperty with another individual(s) beside spouse and/or another veteran.
This applicaUon is made for the purpose of obtaining $� / / y� deduction from the assessed valuation of the following described taxable
property tor the year 20_
Taxi istrict (cify, fown, township) Is�thf�property in queslion: Parcel or Key umber
..L �Heal Pmperty ❑ Mobile Home QC 61.1-7) �6 - a 3_ �.-a o�- oo i.�
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A 'cant was a member of tlie U.S. Artned Forces fa at least 90 days (rw[ rxrxssarily dunng war time� .
B.� �q�• caM vas honaably disdiarged.
C. ►i'App�innt is: ❑ Totally disaded; or ..
❑ At least age 62 wilh ffi least � 0% disabitity
D. � AppGCanYs disabifM1y is evider�ced by ❑ CeNfuate d e6gbtily from the Ind"ena Departrnent ot Veterans FUfa'vs;
❑ Pension certificate:
❑ Awartf of cunpensation hom Veterans Admmistra�n or Departrnent of Defense; or �
❑ Veterar5 AdministraUOn Form 245455 Tax Abatemerrt C�firvte'
E. � The ��� valuatim (al'100%) of the properry for wfiich the deduction is daimed (may rat exceed $113.000) $
F. ❑ Appdxant is die survivmg spouse of an individual who would have 9ualified ta ttie deducUOn under tlds section when he a she Nas alive.
(Age o(deceased eete2n on date W death )
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A Q Applicant was a member of the U.S. Artned Fwces during any of its wars.
B. � Applicant was honorabiy discharged.
C. ❑ Applicant has a service-connected disabiliry of at least 70%
D. � ApplicanYs disabitity is evidenced by. ❑ Certificate of eligibiliry from the Indiana Departrnent of Veterans Aftairs;
❑ Pension certificate:
❑ Award of compensation hom Veterans AdminisUa6on or Depariment of Defense; or
❑ Veterans Administralion Fartn 20.5455'Tax Aba[ement CeAifidte'
E. O Appiicant is the surviving spouse ot an indivirlual whn wrnil�i havr, qualified fa ihe deduction under this sec6on when he w she was alive. �
(Age o( deceased veferan on date of death )
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'� Applicarrt is a vetermi of WaM War I.
AppfinnYs disabdiry is evufenced by. ❑ �ener from Veterans Admin'�sC-atim a DeparVrrnt W Defense; or
❑ Disd�ge doaiments
C. � The assessed valuation (at 700%) of Ne property for wfdtfi the deduction is daimed (may nd excced $163, 000) S
0. 0 The property is Ne apqicarrt's {x'vidpal residence.
E- � The appfic�l ovmed fhe property (or was buy'ux� it untkr omtr�utt) for a[ leas[ me year before the date of Cus appGralim.
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