Veterans_Montgomery;'- E
APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
Stata Form 12fi62 (R71/70�OB)
Presaibed by the Deparimenl N Local Gwemment F'vianoe
�3
INSTRUCTIONS: Please check appropriafe 6ox(es) pertainirn� to tax deduc6'on. (Mors than one box may be checked; however, a surviving
spouse wiro receives a deduction under Section IV may not receive a deduction under SecL'on 11.)
FILING DATES:
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT.
MOBILE HOMES (IC 61.1-7) OR MANUFACTURED HOMES NOTASSESSED AS REAL PROPERTY: DURING THE TVJELVE (12) MONTHS
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDNIDUAL WISHES TO OBTAIN THE DEDTUCTION. ��
❑ I Complete sectionstl, V and Vl.te(IC 6-t.e18- zag�'62 with atleast 10% disa6ility) or surv'rving }pqus�N to �5�,4�1
� 1J
� II Partially service-connected disabled veteian OR surviving spouse - Not to exceed 524,960
Complete sections 11, V and VI. QC G1.1-12-13)
❑ III Wodtl War I Veteran - Not to exceed 518,720
Complete sectiow III, V antl VI. QC 61.1-72-77.4)
❑ N Survivinq spouse of World War I Ve;eran - Not to exceed 518,720
sections N, V, and VI. (IC 61.
Name oi applicant (fip� middle,
JUN 13 2011
�
Applicant Qdces �laes not ) own property with another indivitlual(s) besides spouse antl/or another ve[eran.
This application is made for the purpose ot obtaining 6Onh �the assessed raluation of the fdbwing described tasable
property for Ne
Is the pmperty
� Real P(op
❑ Mobile Hame (IC &1.7-7)
w
A❑ AppGcar� was a member of the U.S. Artned Fwces for at least 90 days (rrot necessanly dumg vrartime)
8. ❑ App6cant was honorady dischafged.
C. � Apptiant's: ❑ TotaOy d�sabled: w
❑ N least age 62 with at I�st 10% disabiGty
D. ❑ AppGnnt's d�saWLry is evidenmC by: ❑ Certificate M d'gibiliry from U�e Indiana Deparfinent of Veterans Aftairs;
❑ Pensbn certifirafe:
❑ Award ot canpensaUm (rom Veterans Pdrtrinistralion or DepartmeM of Dcense: w
❑ Veterans Administration Fortn 20.5455 Taz Abatsnent Certificate'
E. ❑ The assessed valuation (at 100%) d ihe property for wlrid� fhe deduction's daimed (may irot exceed $143,16� S
F. �.4pptin�l is �he wrviving spouse of an mdividual who xrould have qualified for the deduction under Ihis sedion when he or she was alive.
(Age d dereased esteran on dafe d death )
A Q Applicani was a member of the U.S. Armed Forces durifg any of its �rars.
B. ❑ Applicant was honorebly discharged.
C. � Applinnt has a seMce conneGed disabiliry ot at least 10°�
D. ❑ Applitant's disabiliry is eviCenced by ❑ Cer�ifinte of eligibiliry from Ne Irnliana Department of Veterans Aftairs;
❑ Pension certifieate;
� Award of compensafion trom Veterans AdminisVation w Departrnent of Defense; w
❑ Ve[erans Administ2Yron Fortn 20-5455'Tax Abatement Certificate'
E. ❑ Applirant is the surv"rving spouse of an individual who would have qualified for the deduction under ihis section when he w she was alive.
(Age o7 deceesed veteran m date W death )
�QApp&ant is a vetaan of World War I.
�. QAppficanPs servim is evidenced by ❑ Letter from Vetaans Adm'viistration u Departrnent of Defense; or
❑ Dischargedocumenls
C. � The assessed rahiafion (at 100%) of the P�PehY �r wluch fhe deduction's daimed (may nof exceed 82D6,500) 5
D. Q The pmpeAy is ihe appfKant's pmripal rasidence. .... _.
E. �The app5rant ormed the pmperty (w vlas 6uymg it uMer oonhac� fw at leasf one year befure the Eate of tha app&ation.