Veterans_Layman`�`" APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
� 7� �IVWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS (,6 a�
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�; > State Fwm 12662 (R9! 5-061. � ..
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Prescribed �y the Department of LorW Govemment Finance
"���UCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More fhan one box may 6e checked; however, a suiviving
spouse who receives a deduction under Section IV may not receive a deduction under Section 11.)
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION. -
❑ I Totally disabled veteran (or veteran at /east age 62 with at least 10% disability) or surviv�o�e ot to�e�BO
Complete seciions I, V and VL QC 6-1.1•12-14)
❑ II Partially service-connected disabled veteran OR surviving spouse • Not to exceed 524,960
Complete seGions Ii, V and VI. QC 61.1-12-73)
❑ III Worid War I Veteran - Not to exceed 578.720 DEC Q 2007
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❑ IV Surviving spouse of World War I Veteran - Not to exceed 578.720 O��a� ,Q�
Complete sections IV, V, and VI. QC 6-1.1-12-16) l. U
Name of appli t first, middle, last)
Address (streef and numbe �, st te ZIP code) County
�o S ' 66
Applicant ( does I dces not ) own property vrith another individual(s) besides spouse and/or anothe� veteren.
This application is made for the purpose of obfaining S� deduction from the assessed valuation of the fdtowing described taxable
property forthe year20_
Taxing District (crfy, town, township) Is the property in question: Par 1 or Key number � �
❑ Real Property ❑ Mobile Home QC 61J-7) �.3/_ pp_ p6�i.�o1S/-da./
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AppGcant xes a member of the U.S. Artned Fwces tor al leau 90 days (rat necessardy during war 6me}
e. O nva�,t � �ay d�d,aryed.
-C. � Appficant is: ❑ Tofally disaded; or ..
� 0 N least age 62 wiUi al least 7096 disabdity
D. ❑ ApplinnCs disabil�rty is e�idenced by ❑ Cerbfinte of efigibEily from tlie Indiana Departrnent of Veterans Aifairs:
❑ Pension �ficate;
� Award of cwnpensation (rom Veterans Admmistration o� Departrnent of Deferrse; w �
❑ Veterare Admirdstration Form 20.5455 "Tau Abatemerrt CertiFipte'
E. ❑� The assessed valuation (at 700%) of ihe property for whi[h the deduction is daimed (may rwt exceed $113.000) S
F. � Applipnt is tlie wrvivtrig spouse of an indivfdual wim would have qualified fa the deducUOn under tlus section when he or she was alive.
(Age oldeteased veteran m date d deaU� )
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A❑ Applicant was a member of the U.S. Armed Forces during any of its wars.
B. ❑ Applicant vras honorably discharged.
C. � Applicant has a service-connecled disability of at least 10%
D. 0 Applicant's disability is evidenced by: ❑ Certificate of eligibility from the Indiana Departrnent of Veterans ANairs:
❑ Pens certificate;
ward o( compensalion from Veterans Administralion or Department o( Defense; or
❑ Veterans Adminislration Form 20-5455'Tax Abatement Certificate'
E. ❑ Applicant is the surviving spouse of an indiviAiial whn wniilA hava qualified for the deduction under ihis seclion when he or she was alive.
(Age ol deceased veteran on date ol death ) .
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- Appfipnt is a veteren of WoAd War I.
� Fy�pl'Kart's daabdM1y is evider�ced by ❑ Leuer Uom Veterans Adrttinistration a Departmerrt of Defense: a
❑ Disd�alge dowments
C. � The assessed �raluafion (at 100°b) W ihe property tor vRrich the deduc6on is daimed (may not exoeed 3163.000) 5
D. ❑ The prope�ry is the apptinrrt's prmdpa125idence. ,
E. p The app4.ant owned me properry (o. was 6uy'uiy if u.M� con6acr) for al least a,e year bei«e me aace oi mis aPp;catim
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