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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fwm 12662 (R7 / 6-03)
Prescribed by Ne Department ol Lacal Govemment Finance
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INSTRUCTIONS: Please check appropriate box(es) pertaining to tax deducGon. (More than one box may 6e checked; however, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Section ll.)
`JG DATES:
� PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
M BILE 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 disahled veteran (or veteran at least age 62 with et least 70% disability) or surviving
Complete sectlons I, V and VL (IC 6-1.1-12-14)
❑ II Partially service-connected disabled vete2n OR surviving spouse - Not to excaed 512,000
Complete sections II, V and VI. (IC fr1.1-12-13)
❑ III World War I Veteran - Not to exceed 59,000
Complete sec[ians III, V and VI. (IC 6-1.1-12-17.4)
❑ IV Surviving spouse oi World War I Veteran - Not to exceed 59,000
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Comolete sections IV. V. and VI. (IC &1.7-12•16)
Name of applicant ( rst, id , last) _
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Address (sbaet er, an s te) � ��- �-'—" ip coda Co ry
Applicant ( does I does not � own property with another individual(S) 6esides spouse andlor anoiher vete2n.
This application is made for the purpose of obtaining S� d1ed��on trom ihe assessed valuaGon o( the follovring described taxable
propert for the year 20
Tabng District L, t wnship),_� Is th roperty in questlon: Parcel or Key number ' . -�
_ � _ _O_� : ; � - — eal Property ❑ Mohile Home (IC 6-1.1-7) � - � �
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"❑ Applipnt �ras a member of the U.S. Artned Forces for at least 90 days (rrof necessaNy dutig war tlme).
] Applicant vras honwabty d'
.❑ ApPlipnt is: otally disabled: a
t least age 62 with at st 70% disability
D. � ApplicanYs disabiliry is evidenced by: Certificate of eligibility fran the Indiana Department of Vete2ns Aftairs;
❑ Pensim certfirate;
❑ Avrard of compensation from Veterans Adm"utistration or Department of Defense; w
❑� Vete2ns Administratlon Fortn 20.5455'T� Abatement Certificate'
E. 0 The assessed valuation (at 7009'0) of the property for whmh the deduciim is daimed (may rwt exceed 5113,000) 5
F. � Applipnt is the wrviving spouse of an individual who would have qualified for the deductim under this sectlon when he w she was alive.
(Age oJdeceased veteren on date o7death )
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A. ❑ ApD���nt was a member of the U.S. Armed Forces dunng any of its wars. _
B. ❑ Applipnt was honorably discharged.
C. � Applicant has a service-connected disabiliry of at least 10%
D. ❑ ApplicanYs disabiliry is evidenced by: ❑ Certificate of eligibility trom the Indiana Department of Veterens ABairs;
� Pension certificate;
� Award of compensation from Veterans AdministraGOn or Department of Defense; or
❑ Vete2ns Administration Fortn 20-5455'Tax Abatement Certifipte'
� E. L7 Applicant is Ne surviving spouse of an individual who would have quafified tor ihe deduction under this secUon when he or she was al'rve. � �
(Age ol deceased vetersn on date of death 1 . '
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A � Applicant is a veteran of World War I. '
B. � Applicant's disabaity is evider�ced by ❑ Letter frtm Veterans Administralion or Departrnent of Defense; w
❑ Discharge documents
•� The assessed valuation (at 100�) of the property for whidi the deduction is daimed (may rat exceed 5163,000) S
D. 0 The pioperry a the applicant's prindpal residence.
E. ❑ The appficant ovmed the property (or wds buyirg i! urMer con6act) fw at least one year before ihe date of this application.
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