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Form Number 12A - Revised 19li
Prescribed by State Board of Tax Commissioners �7 ��
I U
�� '- VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Application for Deduction From the �"— �7
'�\ Assessed Valuation of Taxable Property
�� *** ¢ual'`ications On BacY. ***
A'ATE OF INDIANA .�Cy��iW¢-!i7'CJ COUNTY,
(Name)
that (s)he is
, , being duly swor on oath says
years of a, that (s)he resides at�
in ' County, Indiana; that (s)he
Check One: �as 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: �/ �, 1��^
` ���� uV
��PeI1SlOn CBTtlficdtE Or l\ '
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
/� appropriate branch of the armed forces
� \
.,� ibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15 /� o,�L _ �� O a
�9� T — .3 00 °
That this application is made for the purpose of obtaining $��
(not to exceed two thousand dollars) deduction from the assess.ed valu-
ation of the following described taxable property for the year 19�,
to wit:
TAXING DISTRZCT
LEGAL DESCRIPTION OR KEY NUMBER
IL�+
That, in above amount of $ deduction applied
for in this u�'(� � s or intends to apply for $� decluction
in
h+IH'{ Q 14�^ County,
� . � . ��ts�:�
AUDITOR
Subscribed and sworn to before me,
��
,y of /�%Qh—e'�� , 19�p .
Taxing Di�strict.
.�,
x ,l�i �,., .,1'd . , '
(Applicant/G rdian��
.��
and disability verified this � �-
�4 i��.,��.1
. Auditor
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