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F�rm Number 12A - Revised 1985 � '
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNE�ED DISABILITY
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and Application for Deduction From the 2/
� Assessed Valuation of Taxable Property �~� �s1993
'�' **• Qualificat�ions On Back *** �
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STATE NDIANA COUNTY, ss: NuDITOR�
(Name , being duly sworn on oath says
that (s)he is � years age; that (s)he resides at
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in County, Indiana; that ( he
� �395 S s ��s
Check One: was a Member of the U.S. Ar�d Forces during� �ny o
its wars �� �jr� �y7c�s
or the widow of a member of the U.S. rme Forces
" who served during any of its wars
and who� 1 discharged therefrom and has a service-
connected.disability of ten percent (10 percent) or more and is
enti-tiea 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 Reti ement Board of the
appropriate branch of the armed forces �/
•exhibited to the County Auditor. ���1w��� I r"" �Wi�
71 � /4-=C✓
IC 6-1. 1-12-13 and 6-1. 1-12-15 �_/ 9,U/ �y
That this application is made for the purpose of obtaining $�O v 0
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 191� ,
to W�t: � ^(]aa I -oo�`� �
TAXING DISTRICT oC�'1 �
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ deduction applied
for in t is County, (s)he has or inte s to apply for $ deduction
in County, Taxing istrict.
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( ppli an Guar ian) �
Subscribed and sworn to before me, and disability-verified this a 9
•day of ' , 19� �, ,
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Auditor