Veterans_KochForm Number 12A - Revised 1977 �� �
Prescribed by State Board of Tax Conmissioners
.' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
` �, and Application for Deduction From the /
r Assessed Valuation of Taxable Property 7— oZ
� *** Qualifications On BacY ***
� STATE OF INDIANA ��\� COUNTY, SS:
I� (Name) � � , being duly sworn on oath says
` that (s)he is years oi age; that (s)he resides at
f in � n� County, Indiana; that (s)he
� Check_One: was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S. Armed Forces
who served during any of its wars
I
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:
, �ension Certificate or
j / 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
�exhibited to the County Auditor.
' /9�� - yo 00
IC 6-1. 1-12-13 and 6-1. 1-12-15 m�
� - /9��i— 3]0���
That this application is made for the purpose of obtaining $%����/`-'
1
(not to exceed two thousand dollars) deduction from the assessed valu-
1
( ation of the following describ�ed taxable property for the year 19 �,
� to wit:�q ggg��� /'� _` -
� TAXING �T�I� �� /
� LEGAL DESCRIPTION OR KEY NUMBER
� V a '�a� � .
( That, �rtAPa�ddition to the above amount of $ deduction-applied
I for in ��iis�aC��,t,�t.,�Bf�e has or intends to apply for $ deduction
AU�ITOR �
� in County, Taxing District.
�Jj ,, .,
X !/in�/',v//� c /�-�i ���;�
(Ap icant/Guardian) •
� Subscribed and sworn to before me, and disability verified this �
day of \ _ , 19� : ,
� �� i ��,�.�.�
Auditor