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Form Number 12A - Revised 1985 ��
Pre:�cribed by State Board of Tax Commissioners .-
� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
� and Application for Deduction From the �
Assessed Valuation of Taxable Property �
'*� Qyalifications On Back •** ��� -� .�'
STATE OF INDIANA COUNTY, SS�FE� 1 1?OOO
(Name) (.�J �° , , being duly worn�o'J�a�say�s
n X
�hat (s)he is �_ years of age; that (s)he resides a@� -'� `�j�J� `D��� �
'n County, Indiana; at (s)he
Check One: �s a Membes 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 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 $�%��
(not to exceed four thousand dollars) deduction from the assessed valu-
?�p00
ation of the following described taxable property for the year _,
to wit: 'I-�� '
TAXING DISTRICT �1/K�'� � �
LEGAL DESCRIPTION OR KEY NUMBER[��C!—!=(-/.ClO�S3�"OV
That, in addition to the above amount of $� deduction applied
for in this County, (s)he has or intends to apply for $� deduction
in ���wc��u�' ' CountY. (�/�M'�' I Taxj.ng District.
��. � X.
7�' • (
(App cant/Guardian)
� Subscribed and sworn to before me, and disability verified this �
� d a y o f �....Q�i , '�S� V [/ v � / , %�
(i`J
Auditor