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APPLICATION FOR TAX DEDUCTION FOR.DISABLED VETERANS,
WWI VETERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS
State Fwm 12662 (R91 SOB)
Resvibed by Ihe DepanmeM ot lmal Govemment Fnance
�RUCTIONS:
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Please check appropriate box(es) pertaining to tax deduction. (More than one 6ox may be checkeT
spouse who receives a deduction under Section IV may not receive a deduction under Section Il.)
FILING DATES: �—
REAL PROPERTY: DURING THE 12� (��� S���
MOBILE HOMES (6-1.1-7): DURING 1 1`J�-
OBTAIN THE DEDUCTION. �+��,_IJYY-�J �_
❑ I Totally disabled v i !L .��y�.L�
Complete sectionsl ��� �
❑ II Partially service-co � ��,�
Complete sections' ��
❑ III World War I Vetera �_ p"G�'-a— ��
Complete sections�....-.-_....-.�—i�co-��r�=�z-i7:a�—
a surviving
= YEAR THE DEDUCTION IS TO APPLY.
2 OF EACH YEAR FOR W�H�I�UAL WISHES TO
�ast 70% disabiliry�ur�iin � t o exceed 512,480
❑ IV Surviving spouse of World War I Veteran - Not to exceed 518,720
Not to ezceed 524,�� 4 2���
� oUN �p p1Y0�
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Complete sections IV, V, and VI. pC 6-7.1-72-16)
Name of a O (first, iddle, J�5!) ,
Address (s(reef a� n mber, city; afe, ZIP code) CoyS�ty S�'
�� % � �. Lu s b i/�� �Q�. '�?G � � C��
Applicant ( does I does not ) wm property vrith another individual(s) besides spouse a�lor another veteran.
This application is made for the purpose of obfaining S deduclion from the assessed valualion of ihe fdlrnving desc+ibed taxable
property for�he year 20_
Taxing ' triG (�, town, township) Is t property in Quesdon: Parcel or Key number -
�' Real Property ❑ Mobile Home (IC 61.1-7) G/�/- p/- 0?00 - UUD.���- ���
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A❑ AppGcant was a of ihe U.S. fvmed Forces for at least 90 days (not necessardy during war Ome}
B. ❑ App6cant was haiorady disdiarged. ,
C. ❑�cant is: ❑ Totaly disaded: a ..
� ❑ At least age 62 with at leasl 70%disability
D. ❑ PypGcanYs disabifity is e�iderroed by � Ce�tifxate of e6gibdity Gom Me Indiana Departrnent of Veterans Aftairs;
❑ Pensim cerUfim�e:
❑ Award ot canpensalion hom Veteraru Adrtrinistration or Departrnenl of Detense; a �
❑ Veterans Administralion Form 245455'iax Abatement Certificate'
E. 0� The assessed valuation (at 100%) of ihe property (or whid� the deducfim is daimed (may rat exceed 5113.000) S
F. � Appfxant is the wrvivmg spouse W an ird�ivbual wiro woufd have qualified for tlie deducUrn under th"s secfion when he or she was alive.
(Age oldeceased veteran on date d death )
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A � Applicant was a member oi the U.S. Artned Fwces during any of its wars.
B� Applicant vras honorabty discharged.
C. ❑ Applicanl has a service-connected disability of at leas� 10%
D.`�f ApplicanPS disabiliry is evidenced by � Certific�ate of eligibiliry from the Indiana Departrnent of Veterans Attairs:
❑ Pensian certificate;
❑ Award of mmpensalirn hom Veterans Administration or Deparimeot of Defense; or
❑ Veterans Adminisvation Form 20-5455'Tax Abatemen[ Certificate'
E. � Applitant is the survrving spouse of an indivufi�al whn wrnd�i havr, qualified (or the deduction under this section when he or She was alive.
(Age oldeceased veteran on dafe oldeath )
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�Applicarrt is a veteran ot WaW War I.
Applirmi's disab8ity is eviderced by ❑ Letter fran Veterans Administrabon or Departrr�rt of Defense; a
❑ Disdiart�e documents
C. � The assessed valuation (at 100%) of the properry for N?iidi ihe deducUOn is davned (may rrot exceed S 163,000) 3
D. 0 The pmperty is the appli�anYS pindpal residence.
E. ❑ The appficant owned tlie popeiry (w was buyirg d ur�er oontr�ac� for at least me year before ihe date of this apptication.
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