Veterans_FarrisForm Number 12 - Revised 1977
Prescribed by State.BOard of Tax Commissioners
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SI _ ��`� � • ��i
VETERANS, OR THEZR WIDOWS, STATEMENT�OF TOTAL DISABILITY
� and Application for Deduction From the
Assessed Valuation of Taxable Property �j�. �
� *** Qualifications on Back *�* �y
STATE OF INDIANA � lY^K�/O�\ COUNTY, SS:
(Name) �_,L.C}lln��° -}(,li1f�,(� , being duly sworn on oath says
that (s)he is � years of age; th'at (s)he resides at � .�1 Q Yi.N�i
(�aaNn�� in ���}�� County, Indiana; that (s)he
/�, �
Ch ck� was a nurse
v �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 d of Compensation or
eterans 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.
' 1C s-1. i-12-1a ana s-1. 1-12-1� /99L ��000
That this application is made for the purpose of obtaining $�
(not to exceed one thousand dollars) deduction from the assessed valua-
TAX� ���(CTT1�,dTOWN1bTOWNSHZp�e property for the year 19�, to
wit:
LEGAL D��R��jT1I�� qR KEY �NUMBER �
P� NE%- sE �- / S-1-g
�atJ ' ad tio� t� r,��� a�b�ov �ui
s �i �J (�+�Cl`'C'.ls,�C--�'°'"`"a�.
--- for in;ltlfYl§O�ouvy, (s)he has or intend
�.
in
County,
-� � 6 0�
� � 3edu n applied
to apply for $ deduction
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 �,
x -�'„Co--��,�' `� . �"—�'''� ;.
. (Appl' ant/Guardian)
Subscribed and sworn to before me,
� day of , 19��
and disability verified this
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