Veterans_ChristmasForm Number 12A - Revised 1977 �
Prescribed by State Board of Tax Commissioners
` + VETERANS, OR�THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
` and AoDlication for Deduction From the d� �'�
Assessed Valuation of Taxable Property
� **x Qualifications On BacY, ***
STATE OF INDIANA „ �� COUNTY,
(Name) de�, being duly sworn on oath says
that (s)he is years of age; that (s)he resides at '`��u���
�/� l,(f. ��,�� in County, Indian_a; that (s)he
Check One: � was a Member of the U.S. Armed Forces'during any o:
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: �
Pension Certificate or
Award of Compensation or
�_ Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement percent disability or more from the
De artment of t n s ilit Retirement Soard of the
appropriate br h��l� m� forces
�exhibited to the County A��i�t�sZ.�0�2 ��(����I}
V /��� � �OD�
\1IC�6 1-12-1 an�d�l. 1-12-1� / 9���
.�� e 4J ,j p o 0
That this application j:�$1Qh� o' the purpose of obtaining ��9�
�
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 doZ,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $
for in this County, (s)he has or intends to apply for
in
County,
�,,
— ��
deduction applied
:� .
$ deduction
Taxing District.
X S�.if.�.I�, isC/.��n. i�.-�
(Applicant/Guardian)
Subscribed and sworn to before me, and disability verified this �a�-
day of � � , 191rz-
,%LD i.t.�-.�-�-..�--
Auditor
� ��