Veterans_JinesAPPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
� WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Fwm 126621R71 / 7P08)
° , Preuri6ed by lhe Depa(iment d Laal Gwemmenf Finance
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INSTRUCTIONS: Please check appropriate 6ox(es) pertainim� to lax deduction. (More fhan one box may 6e checked; however, a surviving
spouse who receives a deduttion under Section IV may not receive a deduction under Secfion Il.)
FILING DATES:
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT.
MOBILE HOMES (IC 6-1.1-7) OR MANUFAC7URED HOMES NOTASSESSED AS REAL PROPERTY: DURING THE TWELVE (72) MONTHS
BEFORE MARCH�31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTION.
� I Tofally tlisaWed veteran (or veteran at leasf e9e 62 wdh at /east 1� disebility) or survivirg spouse - Not lo exceed 512.480
Complete sections I, V and VI. (IC 6-7.1-12-14)
� 11 Partially serrice-connected disaWed vetefan OR surviving spouse - Not to exceed 524,960
Complete sectbns II, V and VI. QC E1.1-12-13)
❑ III Wodtl War 1 Veteran - Not to exceed 518,720
Complete sections III, V antl VL QC 61.1-12-17.4)
❑ N Surviving spousa of World War I Veteran - Not to exceed 518.720
Complete sections N, V, and VL QC &1.1-12-16)
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Name o� appl' i first, middle, las� � � Date of birth (monfh, day, yea�
Address (street a d number, dty, sta e, arM code) Ca ty
Applicent Qdoes �fces not ) ovm property vrith another individual(s) besides spouse andlor another veteran.
This applicatbn is made far the purpose at obtaining 5�3 7��� deduction ffom the assessed raluation of ihe fdbwing described taxable
property far the year 20_ ,- Z — 1�
�Ta�drg Distric[ (city, town, townsliip) Is [he property in Ques[ion: Parcet or Key numbu 2 -�Q�
❑ Real Pmperty ❑ Mobila Home (IC 6-1.1-7) '�. � c,/ ��()
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A❑ App6cant vras a member of the U.S. Artned Forces for at least 90 days (rrot newssanly dur'vg �rar fime�
B. � App6cant vres tonorady Eischa�ged.
C. ❑ App6raM is: ❑ TotaOy disabled: or
❑ At least age 62 with at Imsi 10% disabitity
D. ❑ App&anYs d�sabLty 6 a�ridenced by Cerifica:e M d'x,pbitity from Uie I`d'ana Department d Ve;erans Aftairs;
Pension certfirate;
❑ Avrard of arnpensatim fran Veterans Pdministratim or Depariment of De`ense: w
❑ Veterans Administration Form 20.5455 Tax Abatement Certifimte
E. ❑ The x�=�� valuation (at 100%) d ihe property fw whid� Ne deduction 6 daimed (may iat exceed E743,160� S
F. ❑ AppGcant is ihe siuv"ning spouse of an vMividual who wouW have qualified for the dedudion under ihis section when he a she was alive.
(Age d de[eased veteren on date d death )
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A. ❑ Applicant was a member of the U.S. Armed Forces during any of its vrars.
B. � Applirant was honorably discharged.
C. Q Appiinnt has a seMce wnnected disabiliry of at least 10°�
D. � AppGcanYs disability is evidenced by � Certificate of eligibiliry from the Indiana Department of Veterens ARairs;
❑ Pension certificate;
❑ Axard ot compensafion from Veterans Adminisvation or Department of Defense; w
❑ Veterans Administration Fortn 20-5455'Tax Aba;ement Certificate'
E. ❑ Apdirant is Ne surirving spouse of an individual who would have qualfied for the deduaion under this seaion when he w she was alive.
(Age o1 tleceased veteren m date ol death )
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0. QAppficant is a veteran of World War I.
�, �qpp&zM's servrz is evidenced by ❑ Letter from Veterans Adrtdnstration a Depariment o( Defense; or
❑ Disdiarge documents
C. ❑ The asscssed valuation (at 10096) of tlie pmperty (w whch �he dedudion's daimeC (maynot exceed 8206,500) S
D. ❑ The pioperty is fhe appfranPs pr'vripal residence.
E. ❑The app6mnt amed the pmpaty (w xas 6uy"u�g if vMe� cmtracnlw al leasf one year befoie the date of iha appGcation.
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