HomeMy WebLinkAboutVeterans_FryeForm Number 12A - Revised 1977
Prescribed by State Board of Tax Commissioners
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
and Apolication for Deduction From the ��
Assessed Valuation of Taxable Prooerty
**� Qualifications On BacY ***
STATE OF INDIANA �,ii�j COUNTY,
(Name) ����y, �� �'��Q_ , being duly sworn on oath says
that (s)he is ��_ years of age; that (s)he resides at
- in o�A 1,�� County, Indiana; that (s)hf�0��
Check One: was a Member of the U.S. Armed Forces during any of �
/ its wars P-�y1
�/ or the widow of a member of the U.S, Armed Forces
who served during any of its wars� 3-3 �,a �
and who has been honorably discharged therefrom and has a service '1
connected disability of ten percent (10 percent) or more and is ���✓1(}Z�N
entitled to this deduction as evidenced by: .
�exhi
T
(not
atio
to w
TAXI
LEGA
Pension Certificate or
Award of Compensation or �
VP rans Administration Form 20-5455
nt disab
�isabilit
i
�rmed for
%
s-i. i-i
the pur
deducti
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��a-a d � ,o
P N"" � ����Qp �a
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u-
���� �� ��xable property for the year 19 Q�
That, in addition to the above
deduction applied
forc��qg- �hh n y (s)he has or intends to apply for $ deduction
in ��y��9'� County, Taxing District.
�i:'ri;� d � .a� X
t
\, „� t ( pplicant/Guard an)
� Wtis��crp�mkTC� sworn to before me, and disability verified this
day of mQJL. , 19 Od- ' .
3
uditor �