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Form Number 12A - Revised 1977 ��Q gd
Pr,e;scribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Application for Deduction From the �� /
:� Assessed Valuation of Taxable Property
*** Qualifications On Bac'r. ***
STATE OF INDIANA ��,��� � COUNTY,
(Name) �-,�_ �T,��_ya , being duly
that (s)he is lo a years of age; that (s)he resides
Check One:
in
sworn on oath says
at
County, Zndiana; that (s)he
was a Member of the U.S. Armed Forces during any o`
its wars
o the widow of a member of the U.S. Armed Forces
who served during any of its wars
and who h.as 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:
Pension Certificate or - �
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
r appropriate branch of the armed forces
� exhibited to the County Auditor.
�� — t�l p O O
IC 6-1. 1-12-13 and 6-1. 1-12-15 ��� _ 3 0 p p
That this application is made for the purpose of � taining $� � �"
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 � Z-
to wit:
TAXING DISTRICT
LEGAL DESCRIPTIO
That, in addition to tne above amount ot y
�
for in this County, (s)he has'or intends to apply for
aeauctron appiiea
$ deduction
in County, Taxing District.
���`� X��. �;..�,,,
(Applicant/Guardian)
o tiag? .
_-� `,{NC��sc�ribed and sworn to before me, and disability verified this:��
d ` , 19 �2�
� . � ' Avp�i
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