Veterans_Dukert• 4 WWI V TEIRANS AND�URV�IVING SPOUS S' FB ERTAIN VETERAN� ����
StateFortn12662(R71/10-08) DEC 15 2011
S � Prescnbed by ihe Oeparimenl af Local Gwemmenl Finance
INSTRUCTIONS: Please check appropriate box(es) pertainirn� to tax deduction. (MOre than one box may 6e sh ' ve�, a surviving
spouse wlro receives a deducGon under SecUon IV may not receive a deduction under Sec`�ion �l.
FILING DATES:
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT. GIBSON COUNTY AUDITOR
MOBILE HOMES (IC 6-1.1-7) OR MANUFACTURED HOMES NOTASSESSED AS REAL PROPERTY: Dk�JGGG���TTT iVJ 72 MONTHS
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCJrl�NA �
❑ I Totally disabled vete2n (or veteian af least age 62 wifh af least fOYe dise6ility) or surviving sp�se -#at 2
Complete sections I, V and VI. (IC 6-1.1-12-14)
❑ 11 Parfially serviceconnected disaWed veteran OR surirving spouse - Not to exceed 524,960 DEC 1 5 2011
Complete sections II, V and VI. QC G7.1-12-13)
❑ III Wotltl War I Veteren - Nol to exceed S'18,720
Complete sections III, V and VI. (IC G7.1-12-17.4)
❑ N Surviving spouse of World War I Ve;eran - Not to exceed 518,720
C.'J.IV _ V
GIBSON COUNTY AUDITOR
Complete sections N, V, and VI. QC 61.1-7246)
Name of applit�nt (fi�, middle las�
Address (street and number, dty, siate, andZlP ) � County
b° 7 S. � �o S .�-�°'-'
Applicent �does Qioes not ) own property wi�h another individual(s) besides spouse and/or another veteran.�-I ��O 7�
This application is made for the purpose of abtaining S �"'1 ��) deduction from ihe assessed �aluation of the following desaibed taxable
property fa ihe year 20
axirg � trict (city, own, tnwnship) Is the property in question: Parcel w Key numEer
ealProperty ❑MOdleHome(IC6-1.1'7) a -1'/(o'/OOCO,'J ��5oa�
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A❑ AppGraM was a melnber of Ne�U.S. Artned Forces for at IPast 90 days (rrot necessany dumg war6me}
B. ❑ APP&ant was tqnarady discha�ged.
C. Q Appficard "a: ❑ TotaAy disabled: or
❑ At least age 62 with at I�st 10% disabiGty
D. ❑ App&xnYs d�sabdty a evidenwd by. ❑ Certikaie of eliry'bifiry Gam ihe Indiana Departrnent aF Vete2ns Afttirs;
❑ Pensioncertificate;
❑ Avrard of arnpensatlm from Veterans Administratim or Department of DeFense; or
❑ Ve[erans Adrttlnistration Form 2P5455 "fau Abatanent Certfipte'
E. ❑ The assessed vaWation (at 100%) of ihe properry fw wtedi ihe deduction 5 claimed (maynot exceed 5743,1fi0') S
F. �App6cant is ihe survrving spouse M an uidiW ual who vrould have qualified fir ihe dedudion under Uiis section when he or she was alive.
(Age d demased vsteran on date d death ) ,
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A. Ap � nt was a member of the U.S. FUmed Forces duri�g any of its wars.
B. plicant was honwably discharged.
C. Q Applirant has a serNCe connected disabiliry of at st 70%
D. ❑ AppGpnt's disabiliry is evidenced by �.ertifirate of eligibiliry from the t�iana Department ot Veterans Af(airs;
❑ Pension certificate;
❑ Award of compensation from Veterans AdminisVabon w Department ot Defense; or
❑ Veterans Administration Form 20-5455'Taz Abatement Certificate'
E. ❑ Applirant is Ne surv'rving spouse ot an individual who would have qualified for ihe deduction under this sectbn when he or she vras alive.
(Age W deceased veteran on date o! death )
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�A QApp6cant is a vetrlan of World War I.
B, �Appfica�ri's service is evidenced by: ❑ Letter from Veterare Adrtdnatra�ion a Depertrneni of Defense: w
❑ Diuharge tlowments
c. ❑ ma assessed �an,aeor� �a� �arw) or ma P�oce�r ror wr,� me dea�mor� � aamed (rr�y �o� �oaee saos,soo� s
D. ❑ The properly is the appGCanl's P� residence.
E. ❑The appficant avnetl Ne property (or xas buying if urder con6ac� for at least one year before Me date of ihis apptiratbn.
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