Veterans_VanpattenI Form Number 12A - Revised 19!! Q'y�� �/O� �
Prescribed by State Board of Tax Commissioner�rq� r
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY ��
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i� and Apolication for Deduction From the
Assessed Valuation of Taxable Prooerty �_�
h **• �jualifications On BacY. ***
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I STATE OF INDIANA ���} `� ' COUNTY, SS:
� (Name) ��.�,a'„ �e7, ,�Q,Q� �, �,p �, being duly sworn on oath says
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that'(s)he is � years of age; that (s)he resides at �M �/y�
in- ��Q ,�j.fi� 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 member of the U.S. Armed Forces
who served during any of its wars
and wno 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 Certi£icate" 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. /J
IC 6-1. 1-12-13 and 6-1. 1-12-15 /9 �� % � �O
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That this application is made for the purpose of obtaining $�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER �RQ_Q'r�NP�lA9�
That, in addition to the above amount of $ deducti�on applied
for in (s)he has or intends to apply for $ deduction
in �.� County, � �` ,� Taxin District. .
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f`dAR 1 � iog�
cany/GUarclian
/� �1� ' d. orn to before me,/ �yfid disability verified this �5
�aUD1T0 ✓
day of , 19�
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