Veterans_Stiles�"" APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, �
° WWI VETERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS ����
� > State Fartn 12662 (R9 ! 5-08) .
• µ Prewibe0 by the Departmem of Loral Cwvemment Finance
�RUCTIONS: Please check appropriate box(es) pertaining to tax deduction. (MO2 than one box may 6e che����er,� surviving
spouse who receives a deduction under Section IV may not receive a deduction under Section 11.) ��Q
FILING DATES:
REAL PROPERTY: DURING THE 12 MONTHS BEFORE JUNE11 OF THE YEAR THE DEDUCTION IS T APP �
MOBILE HOMES (6-1.1-7): DURING THE 12 MONTHS BEFORE MARCH 2 OF EACH YEAR FOR WHIC &SQ����SI��HES TO
OBTAIN THE DEDUCTION. uNT y q���TO
� I Totally disabled veteran (or veteran a( least age 62 with a( feasi 70% disability) or surviving spouse - Not to exceed St 2.480 R
. Complete sections I. V and VI. QC 6-1.b12-14)
� II Partially service-wnnecied disabled veteran OR surviving spouse
Complete seUions II, V and VI. (IC 6-1.1-12-13)
❑ 111 World War I Veteran - Not to ezceed 518.720
Complete sections 111, V and VI. QC 6-1.1-12-77 4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 578.720
Not to exceed 524,960
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Complete sections IV, V, and VI. (IC 61.1-12-16)
Name o( applicant (first, middle, last)
Address (street and number, city, state, ZIP code) Counry
-Z/ �E v/S Si �R�nlceT�n/, =N. 5'?G7o �rBSan/
Applicant ( does I dces nM ) own property with another individual(s) besides spouse and/or anoMer veteran.
-7 c/ 9�
This appliration is made for the purpose of obfaining S J 7 /�` �. deducUon from the assessed valuation of the following desuibed tazabte
propeAy for the year 20_
Tazing Districl (crty, town, township) Is the property in queslion: Parcel or Key numher
._ ❑ Real Properry ❑ Mobile Home (IC 61.1-7)
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A Applicant v.as a member W tlie U.S. Armed Forces fa at least 90 days (rwf necessardy durirg war Ome}
B. � AppGqnl v.as horarably disdiarged.
C. 0 ApWinrrt is: ❑ Tofally disaded; a _ .
❑ At least age 62 wilh at least 10% disability
D.� AppGcanPs disability is evidenced by. � Certifxate of e5gibBity fian tlre Indiana Department of Veterans AHairs:
❑ Pensim certifinte:
❑ Award of oomperrsation 6om Veterans fWmmi50-ation or Departrnent of DeferSe; or
❑ Veterare Admm'strabon Form 20.5455'Tax Abatemerrt Certlficate'
E. ,,,Oyyy���� rne assessed valuasm (at 100%) or me poperty ror wr,ici� me deaucti«, is da'uned (may nor exoeed sns,000) S
F. yy Ap�cant is tlie survhmig spouse G an irdividual who wpAd have qualified for ihe deductim under th5 section when he a she was alive.
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(Age o/deceased �etesn on date a/death � )
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A � Applicant was a member of the U.S. Armed Forces during any of its wars. 6
B. ❑ Applicani was honorably discharged. �/ i 6 JG �
C/ (�
C. � Applicant has a servicetronnected disability of at least 10% �
D.�Appiiranfs disability is evidenced by: �Certifica[e of eligibiliry from the Indiana Depa t of Veterans AHai
❑ Pension certificate:
❑ Award of mmpensalion (rom Veterans Administration or Department of e
❑ Veterans AdminisUa6on Fortn 20.5455'Tau Abatemenl Certificate'
E.� Applicant is ihe surviving spouse of an indiviAuai whn w,rn`i41 havr, qualfied for the dedudion under this section when he or she was alive.-�
��(Age o/ deceased veteran on date o/ death % 7 )
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�"-1 �nnt is a veteran of World War I.
i :lppiicarrt's disaWlity is evidr.nced by: ❑ Letter fran Veterans Administration a Department d Defense: or
❑ Disdiarge dowments �
C. ❑ The assessed �raluation (at 700°�) of the property for whidi the deduction is daimed (may not exceed 5763.000) 3
O. ❑ The proP�Y is the appGcaiA's prmdpal residence.
E. ❑ The appficant owned the popelty (w was buyirg it urMcr contract) fa at leasi me year before the date of tha appGcatim.
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