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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fmn 12662 (R9 / 5-Oe)
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� PresaiDed by ihe Oepartmenl of Laal Govemment Fnance �� ii ��..
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�UCTIONS: Please check appropriate box(es) pertaining to tax deduction. (MO�e than one box m c cked; however, a swv�ving
spouse who receives a deduction under Secfion IV may not receive a deduction un Se ron-1}j1 -�—J
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE11 OF THE YEAR THE DEDUCTION IS TO A��%/. O Z ZOO9
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION. .
❑ I Totally disabled veteran (or veteran at least age 62 vnth at least 70% disa6ilityJ or surviving spouse -
Complete sections I, V and VI. QC'o-7.7-72-1a) GIBS�
1�1 II Partially service-connected disabled veteran OR surviving spouse - Not to exceed 524,960 /
Complete seciions II, V and VI. (IC 6-7.1-12-13J
❑ III World War I Veteran - Not to exceed 518.720
Complete sections III, V and VL (IC 6-7.1-12-77.4)
❑ IV Surviving spouse ot World War I Veteran - Not to exceed 518.720
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Compiete sections IV, V, and VI. (IC 6-1.7-72-16)
Name of applicant (first, middle, last) �
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Address (street and number, cily, state, ZIP code) Counry
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Applicant ( does I dces not ) own property with another individual(s) besides spouse and/or another veteran.
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This applicalion is made for the purpose of obtaining $ c7c y/C C• �� deduGion from the assessed valuation of the foliowing described tazable
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property for the year 2Q -
. Taxin District (dry, town, township) Is the property in question: Parcel or Key number
� ❑ Real Property ❑ Mobile Home (IC 61.1-7)
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A� App6cant xes a merrmer of tlie U.S. Nmed FwcRS far al least 90 days (not neoessardy dunrg war time}
B. � AppGpnt �vas honorahly di5diarged.
C. ❑ MPGnrrt is: ❑ TotaAy disabled: a .
❑ N leas[ age 62 with at leasl 109{, disa6tlity
D. ❑ P,ppGqnCs disability is evidenced by ❑ Certifirate of e6gibdity from ihe Indiana Departrnent of Veterans Alfavs;
❑ Persion t�rtifinte;
❑ Award of mmpensation hwn Veterans Admmistration or Departrnent ot Defense; or
❑ Veterans Adminisbation Form 245455 "fax Abatemerrt Certificate' •
E. �� The assessed vaWalion (at 100%) of fhe properry (or vfiich the deducGon is davned (may not exceed 5113.000) 5
F. � Appfrcant is tlie survrv'vig spouse of an irdividual who wvuld have quaiified for ihe deduction under ths section when he or she was alive.
�(Age ofdeceased veteran on date aI death )
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A� Applicant was a member of the U.S. Artned Forces during any of its wars.
B. � Applicant was honorebly discharged.
C. � Applicant has a service-connec[ed disability of at least 10%
D. � Applicanfs disa6iliry is evidenced by: ❑ Certificate of eligibiliry from the Indiana Departrnent of Veterans Affairs;
❑ Pension certificate; �
,�( Avrard of compensalion hom Veterans AdminisVafion or Departmen� of Defense; w
❑ Veterans AdminisVaUon Form 20.5455'Tax Abatement Certificate'
E. � Applican[ is the surviving spouse of an indivirl��al whn wrn�lA havr, Qualfied for the deducYiwi under this section when he w she was alive.•
(Age o( deceased veteran on date o7 deafh ) .
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�❑ Appfx�ri is a veteran of Wafd War I.
.� Applicartt's disabdity is ev"ulencsf by ❑ Letter fran Veterans Adrtunistration or Department W Defense: a
� ❑ Discharge doaments
C. ❑ The assessed valuatlon (at 100%) of ihe properry fa which ihe deducUOn is davned (may na exceed 8763,000) S
D. � The property is the appticarrt's pmdpal revdence. .
E. � The appficant ovmed tice popeiry (a was bu}vg if urr�er corrR-ad) fw at leau me year before the date of this appliqtion.
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