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Form Number 12 - Revised 1985 QQ �- OO ���/ �•.
nPrescribed by State Board of Tax Commiss��a �� ���
VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DZ�[j,,�', Y /`�
and Application for Deduction From the g��� �
Assessed Valuation of Taxable Property
•** Qualifications on Back **' APR 25�go,
,
STATE OF ZNDIANA OUNTY, SS•/� y�,,�"'
� (,Y.yvi,�p ,f3',��!�y�4s
(Name) �b ing� duly� sword' o�nlTo�ath says
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that (s)he is years of age; that (s)he resides at�'�. �{�'
�.�� in . ��;���W�- 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 O.S. Armed Forces
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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 oz
✓ 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. i-12-15
That this application is made for the purpose of obtaining $ �'D �
(not to exceed two thousand dollars) deduction from the assessed valua-
tion of the following described taxable property for the year 199a.., to
wit: (� 1 �
TAXING DISTRICT (CITY, TOWN, TOWNSHZP) " �J
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
� 7��
(Applicant/Guardian)
Subscribed and sworn to before me, and disability verified this
aS day of , �19�.
� c`��o.� � • � 1.�,P /�
, Auditor v