Veterans_Smithrr
Sorm Number �72A = Revised 1977
Prescribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
� � .
and Apolication for Deduction From the �� ��
Assessed Valuation of Taxable Prooerty n�S �
� *** Qu 1'fications On BacY. *** O� D.
%�%'�� � .
STATE OF DIANA COUNTY, SS: ( �
(Name) , being duly swor oath says
� 3 g years oi age; that (s)he resides at
� '
in County, Indiana; that (s)he
Check On ' was a �Member of the U.S. Armed Forces during any of
/a �y� • 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 ��� �. �
connected disability of ten percent (10 percent) or
entitled to this deduction as evidenced by:
Pension Certificate or � .`"'N 0 � ]99l
Award of Compensation or
Veterans Administration Form 20-5455 "Tax Ab�r �e '�1'o�te" or
_��etter statement of ten percent disability or mor��Jf1i� t e
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 $ QQD• �
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 1� ,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ deduc�,�on appli
for in this County,'; (s)he has or intends to ap ly for $ deduation
�
in �� County, �� Taxing Dis ict.
� X ` �
(Applicant/Guardian�)
Subscrib d and sworn to before me, and disability verified this �
� day of � , 19�.
��i>�� �` � Y�!1�
Auditor" ��