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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS�
State Form 12662 (R7 / 6-03)
Prescri0ed by Ne Department of Local Govemmem Finance
�TRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving
spouse who receives a deduction under Section 1V may not receive a deducfion under Section ll.)
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR �H CTF{T E INDIVIDUAL SHES TO
OBTAIN THE DEDUCTION. fj-1 y��
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❑ I Totally disabled veteren (o� veteran at feast ege 62 with at least f0% disab�iryJ or surviving spouse - Not to exceed 56,000
Complete sectlons I, V and VI. QC 61.1-12-14) 0 C 7�_; Z003
❑ 11 Partialry servica-conneaed disabled veteran OR surv'rving spouse
Complete sectlons II, V and VI. (IC 6-1.1-12-13)
❑ III Worid War I Veteran - Not to exceed $9,000
Compiete sectlons III, V and VI. (IC E1.1-12-17.4)
❑ IV Surviving spouse of Wor1d War I Veteran - Not to exceed 59.000
Not to exceed $12,000
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Complete secUons IV, V, and VI. (IC 6•7.1-12-16)
Name of licant (lrst, middl , last`) ,/�, � __ _'
�C./ :
Ad s(s et an n er, city and state) Zip code County
Applicant ( does 1 does not ) own properry wiih anoNer individual(s) besides spouse and/or anoNer veteran.
This applicatlon is mada for Ne purpase of obtaining $��Q� (� deduction trom the assessed valuation of the following described taxable
property (or ihe year 20
Tapn DiSVict (city, town, township) Is the perty in queslion: Parcel or Ke number _ T /
� eal Property ❑ Mobile Home QC 6-1.1-7) ��Q�.--QO_�_g_ ._�f
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❑ AppGpnt was a member o( the U.S. Fvmed Forces fw at least 90 days (not necessardy durrrg war lime).
B. ❑ P.pplirant vras honwably d'isdiarged.
C. � Applirant is: ❑�, /Tytaly diubled; a
pa At least age 62 with at st 10°� disability
D. ❑ ApplicanYs disabairy is evidenced by: Certifirete o( eligihiliry hom the Irbiana Department of Veterans Afiairs;
❑�, �Pension cerGficate;
lrI nward of compensation from Vete2ns Administration or Department of Defense; or
❑ Veterans Administra6on Fortn 265455 "Tax Abatemant Certificate'
E � The assessed valuation (at 100%) of the property for whi�h Ne deduction is tlaimed (may not exceed $113,000) S
F. � Applicam is the wrv'rving spouse of an individual who waAd have Qualfied fw the deduction urWer Mis section when he or she was alive.
(Age o/ deceasad veteran on date ol death 1
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A 0 Applipnt was a member of Ne U.S. Artned Forces during any of its wars.
B. � Applicani was honorably discharged.
C. ❑ Appliwnt has a service-connected disabiliry of at least 10%
D. � Applicant's disability is evidenced by: ❑ Certificate of eligibility hom the Indiana Department of Veterans AHairs;
❑ Pension cerlificate;
0 Award of compensation from Vete2ns AdministraUon or Department of Defense; or
❑ Vete2ns Administradon Fortn 20.5455'Tax Abatement Certificate'
E. L7 Applicant is the surviving spouse of an individual who would have qualified for the deduction under this sectlon when he or she was alive.
(Age o( deceased veteran on date o! death 1
• . .
�❑ Applicant is a veteran of World War I.
❑ P,pplipnYs d'saa'lity is evideraed by ❑ Letter from Veterans Administra�on w Departrnent oi Defense; or
❑ Disc7iarge documents -
C. ❑ Tha assessed valuadon (at 100 h) of the property for whidi the deducGOn is daimed (may not exceed 8763,000) S
D. ❑ Tha property is the applicanYS principal residenca.
E. ❑ The appficant owned Me qoperty (or was buying it ulMer contrea) tor at least one year betore fhe date of Mis appliration. �
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