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� Form Number 12 - Revised 1985 ��
;Prescribed by State Board of Tax Commissioners .
VETERANS, OR THEIR WIDOWS, STATEMENT O�!T� DISABI���� �
�
STATE OF
and Application for Deduction From the
Assessed Valuation of Taxable Property
**+ Qu�lifications on Back ***
DIANA
COUNTY, SS:
APR 2 8 19°3
AUD��1,cyl�'.S
ITOR °
(Name) oJ�p�,�. �7• �yu.a.�w�- , being duly sworn on oath says
th (s)he is � years of age; that (s)he resides atq.Q.3r,I�G�. �57 .
in tutAa✓ County, Indiana; that (s)he
Check One: was a nurse
� was a Member of•the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
and who served for ninety (90) days or more, not necessarily during the
time of war, and has been honorably discharqed therefrom and has a total
disability 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 Total Disabliity from the Department of the
�Defense
/� _ Disability Retirement Board or the appropriate branch of the
��armed Forces
exhibited to the County Auditor.
IC 6-1. 1-12-14 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 valua-
tion of the following described taxable pr/o�ag ,rty for the year 19 �, to
wit: ��y 1 �f���
TAXING DISTRICT (CITY� TOWN� TOWNS \ 7 l��
LEGAL DESCRIPTION OR KEY NUMBER �l,�nJC °F- �"�-'
That, in addition to the above amount of S� deduction applied
for in thts County, (s)iie ha r intends to apply for S� deduction
in S�l �,�XS4cJ County, �O�L4 Tax�ng District and that
the total assessed value of all his/her taxable property as shown by the
'�/
�
tax duplicates of all counties in which they own prope�rJty is S •
� X !� �f^o � � TT'� .
(Appli ant/G ardian)
Subscribed and sworn to before me, and disability verified this
� d a y o f . 19 - I> - �� �. ����
Auditor