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Form Number 12 - Revised 1977
'rrescribed by State Board of Tax Commissioners
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3g(n=�%00 VETERANS��-OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILITY
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� .. and Application for Deduction
(Name) (�.1-� �J• ��l1�sJ� , being duly sworn on oath says
that (s)he is 'riJ cyears of age; that (s)he resides at Q��•� �mT- �(qq'ti
_�*� in �"� County, Indiana; that�(s)he U
Check One: was a nurse
�was a Member of the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
�
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
�: �a -
Award of Compensation or � j�
�CVeterans Administration Form 20-5455 "Tax Ali�t�Ynent Certificate" or
�, e,�: d1�d 8i'
Letter statement of Total Disabliity from the Department of the
Defense /�p �
Disability Retirement eoard or the appropriate��'SYanch9po�f the
� armed forces ,
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�h� �/e(�5�
exhibited to the County Auditor. ,,,���,1'
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IC 6-1. 1-12-14 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $ 0�0��.
(not to exceed one thousand dollars) deduction from the assessed valua-
tion of the following described taxable property for the year 19�, to
wit: �� �
TAXING DISTRICT (CZTY� TOWN� TOWNSHIP)
LEGAL DESCRIPTION OR KEY NUMBER ��R.o—Q �.�^^�"' °� �
That, in addition to the above amount of S�00�, deduction appli.ed
--- for in this County, (s)he has or intends to apply for $ deduction
in � County, �/�/p,L�J^+i^��� 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 t ey own property is S
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Q /iJl.t� � • �.C�-t.�.' � _�'•e __
__� ``�(Appli% nt/Guardian) �
� Subscribed and sworn to before me, and disability verified this �
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%S3 aay of %%1�/„ , 19�7 . `� �D��J '
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Auditor