Veterans_SkeltonForm Number 12A - Revised 1977 '
,<•Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECT����� '
and Application for Deduction From � '
� Assessed Valuation of Taxable Prooerty.�Y�' 5��
** ualifications On Back *** ,y�e s
STATE O DIANA , COUNTYl�, AUDIT�R���
(Name) , being duly sworn on oat says
that (s)he is � years of age; tkiat (s)he resides at�� �\��
���Q�.., in County, Zndiana; that (s)he
Check One: / wasFa Member of the U.S'. Armed Forces during any of
��— i �s 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 � ' --.
�ward of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
� Department of 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 $ oo D
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable prope� s—t-#e—y�-a.r�_,
to wit:
TAXING DISTRICT
�
LEGAL DESCRIPTION OR KEY'NUMBER
That, in addition to the above amount of $
for this County, (s)he has or intends ta
� �in County,
deduction.applied
for $ deduction
Taxin�c�District.
plicafnt/Gua
/ / �� Subscribed and sworn to before me, and disability verified this
day of , 19�. � . " �
Audit r
i.
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