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Form Number 12A - Revised 1977
Pregcribed by State Board of Tax Commissioners
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY /�_3"�
and Application for Deduction From the
Assessed Valuation of Taxable Property
�*• Qualifications On Bac'r. ***
STATE OF•INDIANA ,,f/_,��� COUNTY,
(Name) �/�u,�-�, ,(9o_�j�.3�'',f , being duly sworn on oath says
that (s)he is years of age; that (s)he resides'at 9// �/� _� �
�G,��� � in ��� -County, Indiana; 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:
Pension Certificate or �
� Award of Compensation or
� Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
Department of the Defense Disability Retirement Board of the
� ' appropriate branch of the armed forces
-t exhibited to the County Auditor.
- IC 6-1. 1-12-13 and 6-1. 1-12-15 , � 9�6 ��� ��
�98�, 3oao
That this application is made for the purpose of obtaining-$�.�ca'
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 �e2,
.
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to wit:
TAXING DZSTRICT
LEGAL DESCRIPTION OR KEY NUMBER �
� �` ,.
'��ia� �iniad it on to the above amount of $ deduction applied
d� c �
� t� � ��-. •` _
for in this Co nty, (s)he has or intends to apply for S ae`duction -
��IAR �9 �°8� '
in County,
,�!e �.�
�{�,lDITOR
Taxing District.
� �/„D�a;�„CP� ��-�
/l (�pplicant/Guardian)
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Subscribed and sworn to before me, and disability verified this��
day of � �y�s� , 19�_
Auditor