Veterans_SchaferForm Number 12A - Revised 1985
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTE S� I Y
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and Application for Deduction From the
� Assessed Valuation of Taxable Property MAY 1 O �999
'** Qualificat�ions On BacY, *•* ��
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STATE OF INDIANA ���SOT: COUNT�� 55�:..�� , �
�tt COU TY AUDII'OR
(Name) � �"� �C , being duly sworn on oath says
�hat La'ihe is years of age; that (s)he resides at R�1 j''f1f�Ce�'c,11
in GI��Sn),( County, Indiana; that (s)he
Check One: _,/ was a Membez 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:
Pension Certificate or
- �/ Award of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
Department o£ the Defense Disability Retirement Board of the
'� appropriate branch of the armed forces
exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $�QQ•
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19gq,
to wit: `,
TAXING DISTRICT PQ�p 1�0�
LE��AL DESCRIPTZON OR KEY NUMBER
That, in addition to the above amount of $1.,00 U deduction applied
for in this County, (s)he has or intends to apply for $ O deduction
in � County, — Taxing District.
X'VI I A�. Y/ _ �f,�� Oh /
, � ( pplicant/Guardian)]�
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� Subscribed and sworn to before me,
day of �Q, ��: , 19�.
and disability verified this
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Auditor
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