Veterans_Holder- i
Form Number 12A - Revised 1977 "�
Prescribed by State Board of Tax Commissioners ��//��//
J � �.
VETERANS, OR THEIR TATEMENT OF SERVICE-CONNECTED DISABILITY �
1 p �
�� �i��%ti'yo�"`�`nd _�1� a n fo�De�ion From .the •� .- JL �s���
As e a uation of Taxable Property
� **� ualificatiorts On BacY. *** .
�� JAN 17 1992
�ATE OF IANA COUNTY,�SS:
� ��"�(Name) (7'�YJVJt�, being duly swo�n,g�,pp,fl*c.h f�
� th (s)he is years' f age; that'(s)he resides'at Q U' 0
� . .�•. 1 _ J.. �ln ...._ ..i.. ., County,�Zndiana; that (s)he� :' -
' �• ' " > , �
— � � Check _One : ' � .was :,a., Member . of .,the .U�. S . ..Armed Forces �,during..any =o-�f-�v� _
� ' ' its wars : " � '
- � '� the widow o-f a member of the U.S. Armed Forces � .� ��
; who served during any of its wars � � ,
_ ... . ...,_ ..-. -- - -_... : ..<.. _ ,..._- . _,, .... �._. ..�.......__. .- _Y ,
��and�who has been honorably discharged therefrom�and has a service- y
connected disability of ten percent (10 percent) or more and is ' '�
- -entitled to this deduction .as evidenced by: . � ---- .
� � Pension Certifi.cate 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 Boazd of the ;
' �� _; . � ' appropriate- branch of the armed . forces �' - � �. . '
��_hibited_to,the County Auditor.-••---•- .-�-�- �-- �O-/-�,•--���`/rs 0 � "
�� � IC 6-1. 1-12-13 and 6-1. 1-12-15 - ' . � ' i
That this application is made for the purpose of obtaining $�:°.
(not to exceed two thousand dollars) deduction from`the assessed valu-, ' �
-- � ation of the following described taxable property for the'y'ear'�19g��i° � �
to wit: � I
TAXING DISTRICT • '
. ... ... .. . .. .
� ,
LEGAL DESCRIPTION OR KEY NUMBER ,
� That, in addition to the above amount of $�ro d o deduction_applied �
for in th County, (s)he has or intends to apply for $ deduction -
I
in ` County, �-�p.� '�(�Caxing District.
. �
. X (Y21%,-. �/Cl. ,c /
� (Apolic t/Guardian)
� Subscrib and sworn to before me, and disability verified this l� '
� of / • � , 19��
�� \ .
Auditor