Veterans_TurpinForm Number 12A - Revised 1977
Pr/escribed by State Board of Tax Commissioners
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-- � VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
. 2 �/
� and Apolication for Deduction From the �o �
� Assessed Valuation of Taxable Property
**• Qualifications On Bac'r. ***
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STATE OF INDIANA ��'�.m COUNTY, S5:
(Name) _�����„ Z'i_��AA� �M , being duly sworn on oath says
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that (s)he is years of age; that (s)he resides at
����_ in ��Qlv� 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 menber of
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 of the Defense Disability Retirement Board of the
appropriate branch of the armed forces
exhibited to
the County Auditor.
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IC 6-1. 1-12-13 and 6-1. 1-12-1� 3 0� a
That this application is made for the purpose of obtaining $�'B
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 � a„
to wit:
TAXING DISTRICT
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0
LEGThaE� � -�oYtheMabove amoun���r� de��d�uction a� lied
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for in tt{�i��c7u�5�Y� (s)he has or intends to apply for $ deduction _.,
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in County, Taxing District.
AUDI70R X � � �, � ���
� � (Appl' ant/Guardian
Subscribed and sworn to before me, and disability verified this � !,
day of M(�� , 19�e� �
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Auditor _
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