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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
1NWI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Form 12662 (R8 / 4-04)
Prescribed by the Department of Local Govemment Finance
INSTRUCTIONS: Please check appropriate box(es) pertaining to tax deduclion. (More than one box may be checked; however, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Section II.J
.�JG 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 FOR WHICH THE INDIVIDUAL WISHES TO
OBTAIN THE DEDUCTION.
❑ I Totally disabled veteran (or veteren at leasf age 62 with at least 70% disability) or surviving spouse - Not to exceed 572,480
Complete sections I, V and VI. pC 6-1.1-12-14)
❑ II Partially service-connecied disabled veteran OR surviving spouse - Not to exceed 524,960
Complete sections II, V and VI. (IC 6-1.1-12-13)
❑ III World War I Veteran - Not to exceed $18,720 '
Complete sedions III, V and VI. (IC 6-1.1-12-17.4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 518,720
Complete seclions N, V, and VI. (IC 6-1.1-12-16)
Name of applica t midd/e, last) '"� � 5 Sto r mo r�1”
PdTnrA� L
Applican[ ( does / does not ) own property with anothe individual( spouse and/or another velera
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This applicatlon is made for the purpose of obtaining S deductlon from the assessed valuation o( the following described taxable
property for the year 20_
Taxing Districl (city, town, township) Is the property in quesiion: Parcel or Key number
❑ Real Property ❑ Mobile Home (IC 6-1.1-7)
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� Appficant vras a member of the U.S. Armed Faces for at least 90 days (rat necessanty dunng war time).
B. ❑ Applicant was honorably discharged.
C. � Applipnt is: ❑ Totally disabled; or
❑ At least age 62 vriN at least 10°h disability
D. ❑ ApplipnPs disabiliry is evidenced by ❑ Certifipte of eligibiliry Gom the Indiana Department of Vete2ns ARairs;
❑ Pension certificate;
❑ Award of mmpensafion trom Veterans Administration a Department o( De(ense; or
❑ Veterans Administra6on Form 20.5455'fau Abatement Certificate'
E. � The auessed valuation (at 100%) of the properly for whi� ihe deducfion is daimed (may not exceed 5773,000) $
F. � Applicant is the surviving spouse of an indrvidual who would have qualified for the deduction uMer this section when he or she was alive.
(Age o( deceased veteran oq date of death 1
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A � Appliwnt was a member of the U.S. Armed Forces during any of its vrars.
B. ❑ Applicant was honorably discharged.
C. ❑ Appliwnt has a service-connected disabiliry ot at st 10°/,
D. ❑ ApplicanCs disability is evidenced by: eAificate of eligibility from the Indiana Department of Veterans ARairs;
❑ Pension certificate;
❑ Awartl ot compensation irom Veterans AdministraGOn or Department of Defense; or
❑ Veterans Administration Form 20-5455'Tax Abatement Certificate' �
E. ❑ Applicant is the surviving spouse of an individual who would have qualified for ihe deduction under this secGOn when he or she was alive.
(Age o)deceased veteran on date o7death 1
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A � AppGpnt is a veteran of World War I. �
� ApplipnPs disabiGry is evidenced by ❑ Letter Gom Veterans Administration or Departrnent o� Defense; or
❑ Discharge documents
C. � The assessed valuation (at 100°/,) of the pmperty tor which ihe deduc6on is daimed (may not exceed S 763,000) $
D. � The property is the applipnt's prirkipal residence.
E. 0 The applicant amed the pmperty (a was buyirg d under contract) for at least one year befwe Ne date of this application.
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