Veterans_Dobson� - �rorm Number :2A =- Revised 19�i � �`" + 'C �
Prescribed by State Board of Tax Commissioners �\�� 91�_�` F-�
l� Cl
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILI�����
and Application for Deduction From the
� Assessed Valuation of Taxable Property
**• Qualifications On Bac;: *** NOV 2 0 1991
STATE OF INDIANA COUNTY, SS: Gn�yv�RJ
(Name) �. ' , being duly sworn on b'aD sO�s
`h t(s)he is �� years of aqe; that (s)he resides at
�P���,�i��_ in ,���y� County, Indiana; hat s)heJ
Check One: � was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S. Armed Forces
who served during any of its wars �
and who has 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 o£ the Defense Disability Retirement Board of the
� appropriate branch of the armed forces
"exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 ,
to wit:
TAXING DZSTRICT
LEGAL DESCRIPTIO
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in • ��� County, p�, �A1TY,�• Taxing District.
— — h
X
pplicant/Guardian)
� Subscribed and sworn to before me, and disability verified this _
day of , 19
� J
Audi or
�