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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Form 12662 (R8 / 4-04)
PresaiOed by the Department of Local Govemment Finance
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INSTRUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (Mo�e than one box may be checked; however, a surviving
spouse who �eceives a deduction under Section IV may not receive a deduction unde� Section ll.)
G DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION IS TO APPLY.
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR�R1�1 TH t�NQI�� WISHES TO
OBTAIN THE DEDUCTION. ��_�
❑ I Totally disabled veteran (or veteran at least age 62 wifh at least 10% disabilifyJ oi sCirviv 512,480 �"z�
Complete secfions I, V and VI. QC 6-t.t-12-14) �`�
� II Partially service-connected disabled veteran OR surviving spouse - Not to exceed 524,9�9AY 0 4 2005
Complete sections II, V and VI. (IC 6-1.7-12-13)
❑ III Wodd War I Veteran - Not to exceed 518,720
Complete sections III, V and VI. (IC 6-t.t-72-77.4)
❑ IV Surviving spouse of Worid War I Veteren - Not to exceed 518,720
GIBSO�p�N�� ITOR
- Complele sections N. V, and VI. (IC &1.1-12-16)
Name of applicant (first, middle, last)
Address (street an umber, ity, state, ZIP code � Coun �/�/
/ � L� /l_J
Applirant ( does / does not ) own property with another individual(s) besides spouse anNor another veteran.
This application is made for the purpose of obtaining 5 deductlon from Ne assessed valuatlon of the follovAng descnbed taxable
property for ihe year 20_ _ �S
Ta�cin isVict,(ciry, town, wnship) Is property in quesiion: Parcel o ber
�-�-� Real Property ❑ Mobile Home (IC 6-1.7-7) _� �O_��
• . . � .. •' �'. . ..
AppGcant v2s a member o( the U.S. Nrmed Forces fw at least 90 days (not necessanly dunng war Gine).
B. � Appfipnt was hono2bly discharged.
C. 0 Appficant is: ❑ Totaly disab�ed; or
❑ At least age 62 with al least 10%disability
D. ❑ ApplinnPs dsability is evidenced by. ❑ Certifinte of eligibility from the Indiana Department of Vete2ns Aftairs;
� ❑ Pension certifipte;
❑ Award of tampensa6on from Veterans Administration w Department of Defense; or
❑ Veterans Administration Fortn 20.5455'Tax Abatement Certificate'
E. � The assessed valuation (a[ 100°/ ) of the property for which ihe deduction is daimed (may rrot exceed 3773,000) $ '
F. ❑ Applipnt is Ne surviving spouse o( an individual who would have qualified fw the dedudion urMer ittis section when he w she was alive.
(Age of deceased veteran on date of death )
• . � ..
A. 0 Applirant was a member of the U.S. Artned Forces during any of its wars.
B. � Applicant was honorably discharged.
C. � Applicant has a service-connected disabili�ty,�of /at least 10°/,
�Applicant's disability is evidenced by: �ertifipte of eligibility from ihe Indiana Department of Veterans Afiairs;
❑ Pension certificate;
❑ Award�of compensauon from Veterans AdminisUation or Department of Defense; or
❑ Veterans Administrauon Form 20-5455'Tax Abatement Certifiwte'
E. 0 Applicant is the surviving spouse of an individual who wouid have qualified for the deduction under this section when he or she was alive.
(Age o/deceased veteran on date o/death )
� . .
A 0 AppGcant is a veteran of Wafd War I.
� ApptipnYs disabi6ry is evidenced by. ❑ Letter Gom Vete2ns Adrtunistration or Department ot Defense; or
❑ Discharge documents
C. � The assessed valuation (at 100°/,) of ihe property for which the deduction is daimed (maynot exceed 5763,000) 5
D. � The property is ihe applipnfs prindpal residence.
E. ❑ The applipnt avned the pmperty (a was buyirg R under contract) for at least one year befae fhe date of llus apptiption.
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