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'�_Form Number 12 - Revised 1985
�;� Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DIS�AB� ��� N tl
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�
� and Application for Deduction From the ��±Y 61gg�
Assessed Valuation of Taxable Property
*•+ Qualifications on Back *** � �t. ��,�,�
�J UDITOR � '�
STATE OF ZNDIANA .��.�oA-ir_J COUNTY, SS:
(Name) ��w�7�_ �/>�c-���eing duly sworn on oath says
� - /- -
that (s)he is � years of age; that (s)he resides at
in � ����County, Zndiana; that (s)he
(�
C�
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 discharged therefrom and has a total
disability and is entitled to this deduction as evidenced by:
Pension Certif�icate 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 appropria•te branch of the
a:med .'.orces �^/ _ Q/��� �y-�
�t�C.Cn tii��
exhibited to the County Auditor.
1C 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 property for the year 19�'�/¢ to
wit: +7j'
TAXING DISTRZCT (CITY� TOWN, TOWNSAZP) � ���7 ����%-
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $� deduction applied
for in this County, (s)iie has or intends to apply for S�I deduction
l � �� � [� .
in ��'� � County, � Q�� t-//i,oaTaxing District and that
2i
the total assessed value of all his/her taxable property as shown by the�
tax duplicates of all counties in which t�y own propert is S�% J.� O
�l/ �
�Ap icant/Guardian)
Subscribed and sworn to before me, and disability verified this
� day of y7��. 19�3 .
��ro � � �e4iL�o
Auditor