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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, "
�� v W1M VETERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS� ��� g�
e, J• State Form 12662 (R915-08) e� �
Presaibed Dy the Department of Lorvl Govemment Finance m•+,
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�tUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (MOre than one box may 6e ch jce�; qoy�v�{oa surviving
spouse who receives a deduction under Section IV may not receive a deduction under Secti�Yl � 1 V CU /
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE11 OF THE YEAR THE OEDUCTION IS TO AP
MOBILE HOMES (6-7.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE �� HES TO
OBTAIN THE DEDUCTION. 01890N CO NTY d 61i'Bp
C� I Totally disabled veteran (or veteran at least age 62 v�th at least ]0% disabiliry) or surviving spouse - Not I 2,480
Complete sections I, V and VI. QC 6-7.1-72•14)
❑ II Partially service-connected disabled veteran OR surviving spouse - Not to exceed 524,960 �
Complete sections II, V and VI. (IC 6-7.1-12-13)
❑ III World War I Veteran - Not to exceed 518,720
Complete sections III, V and VL (IC 6-7.7-72-77.a)
❑ IV Surviving spouse of Wodd War I Veteran - Not to exceed 578,720
Complete seclions IV, V, and VI. (IC 6-7.1-12-76)
Name o( applicant (first, middle, lasf) � Date of birth (month, day, yea�
r � 7
Address (street a n ber, ' ate code) � Coun 2 `�N
��EJJ U/l�
� Appliwnt ( dces I does not ) own property with another individual(s) besides spouse andlor anoNer veteran.
This application is made for the purpose of obtaining S Gi � deduUion from the assessed valuation of ihe following described tazable
p for the year 20_
T p g �s ( to o ship) Is property in question: Parcel or Key number /' q
�.��Q � � Real Property ❑ Mobile Home (IC 61.1-7) ��� , .�O�Q� GOII ••�0�30��
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� A❑ AppGrant was a member of tlie U.S. lvmed Foices fa a[ least 90 days (not neoessarily during war fime�
B. � APPGar�l vras horarably disdiarged.
C. � ApqipM is: ❑ TotaOy disaded; w ..
❑ At Irau a9e 62 with at least �0%disability
D. � ApplipnCs disability is evidented by. ❑ Certifinie W e6gib3ity hom the Indiaria Departnent d VHerens Aftavs;
❑ Pereim cerOfimte:
❑ A�ra/d of canpensation hwn Veteraru Administration oi Department of Defense; w •
❑ Veterans Administration Form 20.5455 "iax Abatemart Certfirate'
E. �� The assessed valuatim (al 100%) ol the property fa vfiidi the deductim is dairtied (rt�y not exceed 5113.000) $
F. � Applipnt is tl�e survivmg spouse W an individual wFro would have qualified fa tlie deducGon under tlus seciion when he or she was allve.
(AgeWdeceasedvete2nondateWdeath )
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A � Applinnt vras a member of ihe U.S. Artned Fwces during any ot its wars.
B. 0 Applicant was honorably disci�arged. � �
C. ❑ Applicant has a serviceconnected disability of at least 10% �
D�AppliwnYs disabiliry is evidenced by. ❑ Certificate of eligibiliry from �he Indiana Departrnent of Veterans Aftairs;
�❑, /g�nsion certifirate; .
�Award ot compensalion from Veterans Administration or Deparlment'of Defense; o�
Veterans Administra6on Form 20.5455'Tax Abatement Certifiwte'
E. � Appiicani is the surriving spouse of an individual whn wrndd have qualified fw the deduc6on under this section when hepr she was alive.
(Age o( deceased reteran on date ol death ) �
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-] Applicant is a veteran af World War I.
:. �] npqkarrc�s e�avry s��oed ey ❑ Letler (TOm Veterans Adrttinistraoon or Departrnerrt of Defense: a
❑ Disd�ge dowments
C. � The assess�ed valua6on (at 700°,6) ot ihe property tor whidi the deduction is daimed (may nd exceed 8763,000) S
D. ❑ The property is the applicanYs principal residence. �
E. ❑ The appfxant owned fhe property (a was buyux� if u�Mer ca,6act) for al leasi one year before ihe date of this applicatiaL
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