Veterans_Poland/
;•� Form Number 12A - Revised 1985
prescribed by State Board of Tax Commissioners � F� �� .
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED.DISI BILITtY„d L"
� and Application for Deduction From the������--'G �995 �
�� Assessed Valuation of Taxable Propert.y
*** Qualifications On BacY. *** �,�,%
AUDITOR��
STATE OF I IANA .� � N COUNTY, SS:
(Name) � , being duly sworn on oath� says
. � C� �S
�hat (s)he is �r� years of age; that (s)he resides at �
in �/a S�� County, Zndiana; that (s)he
Check One: � Was a Member of the U.S. Armed Forces during any of
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 has a service-
connected disability of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by:
Pensio�Certificate or
� Award f Compensation or
Veteran Administration Form 20-5455 "Tax Abatement Certificate" or
✓ Letter statement of ten percent disability or more from the
Departme the Defense Disability Retirement Board of the
�� appropriate br rtch of the armed forces
exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-1�
That this application is made for the purpose of obtaining $ DO
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for
to W�t:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
the year 19�,
��'a1-O�
- n � �i r7 _ ,rv-
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in
County,
� Subscribed and sworn to before me,
day of ��v , 19�!
Taxin District.
X � �`'
' (Applicant/Guardia
and disability verified this
� O �
Audito
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