Veterans_Riley_ � Form Number 12 - :?eJ�;is'ed 1977 ` j�/�
'�P'rescribed by State Board of Tax Commissioners • �� �' / �— Z
- �: 1 ��>--
�� VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILITY
�} and Application for Deduction From the P
Assessed Valuation oi Taxable Property aGl3
. *** Qualifications on Back *** � Qf
STATE OF INDIANA ,��, COUNTY, SS:�-�
(Name) ��� `�,���� , being duly sworn on oath says
� �
that (s)he is �iL years of age; that (s)he resides at
�. 3 in .��, 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 discharged 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
/9�6 - -2 0o a
That this application is made for the purpose of obtaining $�-z?c
(not to exceed one thousand dollars) deduction from the assessed valua-
tion of the following described taxable property for the year 19_, to
wit:
TAXING DISTRICT (CITY, TOWN, TOWNSHIP) .
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in
County,
Taxing 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 property is S
,•� ��� � ;.
��:' (Applicant Guard'an)
� y-�
Subscribed and sworn to before me, and disability verified this I�
� � d.ay of �%��� , 19 �Z-.
�/�D. ����
Auditor�'—