Veterans_Priestly�o_rm Number 12A - xevised 197i
••� .'`�escribed by State Board of Tax Commissioners
-.,
�
' VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Aoplication for Deduction From the � 3��
�Assessed Valuation of Taxable`Property Q �
� **� Qualifications On BacY, *** 11� �
� STATE COWiTY, SS: , �
' (Name) �IL.tiy�. „��J ,•being duly sworn on oath says
��
( that (s)he is years o: age; tha (s)he resides at .
in ��t,�iQ�� County; Indiana; that (s)he
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 t.e..n percent (10 percent) or more and'is
entitled to this deduction as evidenced by:
Pension Certificate:�•or. �
Award of Comp�nsatiOrl' or • -•,
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
� Department of the Defense Disabi�3ity Retirement Board" of the
appropriate branch of the armed forces ,'.i�t �i.�j
�� :hibited to the County Auditor.
� IC 6-1. 1-12•13 and 6-1. 1-12-15 /9 O'� =�� B O
9�rq 3Boa
That this application is made for the purpose of �btaining $�'
(not to exeeed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�,
to wit: �J�'� ��
TAXING DISTRICT Lr-riv/c-Qi � .
�
LEGThaD � in�a��i��YtheMabove amount of
�
for in th����Coun�g,,, (s)he has or intends to
i. � '� ..�GL
in
�AUDITOR
Subscribed and sworn t
� . a y o f � (�j4��
�
County,
x
F� � .
$ deduction applied
apply fo �$ � deduction
axiAq/District
ApplicantJGuardi
o before me, and disability verified this LS
, 190�. •
.�,/. D. ��i��-sL_ j.
Auditor •
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