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"'" APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, ' '
4 WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
.µ 9ale Farm 12662 (R71 / 10-08)
� � Prescnbed by the Departmenl af Lotal Gwemment Fifuncs
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.NSTRUCTIONS: Please check appropriate box(es) pertainirn� to lax deduc6on. (MO�e than one box may be cherked; however, a surviving
spouse wiro receives a deduttion under Sect(on IV may not receive a deducfion under Seclion 11.)
FILING DATES:
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT.
MOBILE HOMES (IC Cr1.1-7) OR MANUFACTURED HOMES NOTASSESSED AS REAL PROPERTY: DURING THE 1WELVE 72�NTHS
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTI� ��
❑ I Tofally disaWed vete2n (or veteran af least age 62 wAh af least 10Ye disa6ility) or surirving spouse ot t S 4
Complete sections I, V antl VI. (IC 6-1.1-12-14)
❑ II Partially serviceconnected disaWed vete2n OR survrving spouse - Not to exceed 524.960
Complete sectbns II, V and VI. (IC 61.1-12-13)
❑ III WoAtl War I Vete2n - Nol to exceed 518.720
Complete sections III, V and VI. QC 61.1-12-17.4)
❑ N Surviving spouse of Worid War I Veteran - Nof fo exceed 518.720
DEC 2 2 2�11
C.'J.r \' V
r_�as[1N COUNTY AUDITOR
Complete sections N, V, and VI. QC 61.1-12-16) `- -
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Name o - nt (firsf. midd! , las� �
Address sheefandnum6er,dty,state,arMZlPcod �o
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Applrenf ddces Qdoes not � own property with another individuat(s) besides spouse antllor another veteran.
This application is made for the purpose of obtaining S a~ 1 tleduction from lhe assessed vdluation of ihe fdbwing described taxable
property fw Ne year 20
Tazing District (city, town, fownship) s t propeRy in question: Par or Key number
Real PmPertY ❑ Mobile Hwne (IC 61.1-7) �' �� � 9_ aoG - oa � s 3�- �
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❑ AppGCaM was a manber of Me U.S. Artned Forces for at least 90 days (rrot newssanly dunng wertime}
B. Q App6cant was honaady disrhafged.
C. ❑ App&ant's: ❑ TotaOy d�sablc�l: w
❑ N least ape 62 with at least 10% disabiBry
D. ❑ AppfiranYs QisaWLry ¢ e�ridenced by �Certificate af eligihitiry from Uie Intlena DepaMrent of Veterans ARairs;
❑ Pensim cerlificate;
❑ Award of compensatim hom Velerans Administratlm or Departrnent of Defense; w
❑ Veterans Administration Fortn 245455 "�ax Abatemeni Certifimta'
E. ❑ The assesse� vahution (at 700%) d the properry for w1iU� the dedudan s daimed (may rat exceed 5143,160� S
F. �AppGca� �s �he surviving spouse at an'vWividual who would have quaGfied for fhe dedudion under this section wh� he w she was alive.
(Age d daceased vst�an ar date d deffih 1
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A � Applicant was a member of the U.S. Armed Forces duri�y any of its wars.
B. ❑ Applicant was honaably dischar9ed.
C. ❑ Applicant has a service conneGed disability of at least 70%
D. Q App6canYs disability is evidenced by ❑ CertlfMate of eligibiliry from the Indiana Department ot Vetuans Aftairs;
❑ Pension certifirate;
❑ Awafd of compensation from Veterans Administratbn w Department of Defense; or
❑ Veterans Administration Fortn 20-5455'Tax Abatement Certificate
E. ❑ Applirani is the wrvrving spouse of an individual who would have qualified for the deduction under this sectbn when he w she vras alive.
(Age o/ deceased veferan on date N death )
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A QApp6ranf a a veteran of World War I.
8. QApp6car8s servi[e is e.ridenceC by: ❑ �etter 6am Veterare Adrtun"stration a Deparimenl d Defa�se; w
❑ Disd�arge documents
�. Q The assessed radiafion (at 10096) of the property for whicn ihe deductim is daimed (maY �t exceed 5206.500� S
D. O The pmperty is the appfKaM's pm�dpal residence.
E. QThe appficant ownea the property (w �rds buying it uMer conlrart� for af least one year before Ne tlate of ths app6catron.
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