Veterans_Ulrey�" APPLICATION FOR TAX DEDUCTION FOR.DISABLED VETERANS,
�r° � WiM VETERANS AND SURVMNG SPOUSES OF CERTAIN VETERANS
;� � Slate Form 12662 (R9 / 5-OB)
w Presmbed by the Departrnent of Local Govemment Fnance
If�UCT10NS: Please check appropriate box(es) pertaining to tax deduction. (More than one box may be checked; however, a surviving
spouse who receives a deduction under Section IV may not receive a deduction under Section 11.)
FILING DATES:
REAL PROPERN: DURING THE 12 MONTHS BEFORE JUNE11 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.
�f I Totally disabled ve[eran (or veteran ar least age 62 vnth at least 70°� disabiliry) or surviving spouse - Noi to exceed�512,480
� Complete sections I. V and VL QC 6-L7-12-14) .
❑ II Partially service-wnnecied disabled veteran OR surviving spouse - Not to exceed 524,960
Complete sections II, V and VI. QC 6-1.1-72-73)
❑ 111 Wodd War I Veteran - Not to ezceed 578.720
Complete seciions III, V and VI. (IC 6-7.7-72-77.a)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 518,720
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Complete sections IV, V, and VL QC 6-7.1-12-16)
Name of appliwnt (first, middle, las!)
Address (sfreet arM number, cily, state, ZIP code) County
E. �TE� ST, � rn,'Gc—on,� !� . �F7 70 �o/dsnn/
Applicant ( dces I dces not � own property with another individuai(s) besides spouse andlor another veteran.
00
This applica6on is made (or Ihe purpose of obiaining S/n� ��� deduction from ihe assessed valuation of the fdlowing described faxable
property for the year 20_
Taxing District (cify, town, township) Is the property in question: Parcel or Key number
� Real Property ❑ Mobile Home (IC 61.1-7) �
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A(� App6cant was a member of tlie U.S. Armed Forces fa al least 90 days (rat necessardy dunrg war tirne�.
B. j4f nppGrant �vas Imnorably disdiarged.
C. � Ap�rant is: � Totally disaded; w ���
❑ At least age 62 with at least 10% disabdity
D. �! AppGranYs disabifrty is evidenced 6y .� Certi(xate of e6gibaity Gom the Indiaria DepaM�ent of V
❑ P� ��: '''I qQ 2009 ,
❑ Award of mmpensation hom Veterans Administration or Department ot+L9E(msE: dt
❑ Veterans Administra�on Form 265455'Ta�c Abatement Certlficate'
E. ❑ The asses.ud valuatim (at 700Yo) of fhe property for wfi"rh ihe deductim is daimed (may not excecd 5713.000) $ �`7�ri _.�-t,C3�«
F. � A{�lirant is the survrvmg spouse W an individual who waAd have qualified fa the dedu�tion under tltis section when he�or she �s alive.
(Ageoldeceasedveferanandatea�deaN ) GIBSON COUNTY AUO�TOR
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A❑ Appiicant was a member of the U.S. Armed Forces during any of its wars.
B. ❑ Applicant vras honorably discharged.
C. ❑ Applicant has a service-connected disability of at least 10%
D. ❑ Applinnt's disabifity is evidenced by. � Certifica[e of eligibiliry irom the Indiana Departrnent of Veterans Aftairs:
❑ Pension certificate; �
❑ Avrard of compensation from Veterans Administration or Department of De(ense; or �
❑ Veterans AdminisVation Form 20-5455'Taz Abateme�t Certifirate'
E. ❑ Applicant is ihe wrviving spouse of an indiviA��al whn wrnikt havn qualfied tor the deduction under this section when he or she was alive.
(Age o/deceased veteran on date o7death )
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Appiicarrt is a veteran of World War I.
. Appiitarrt's disabdity is evider�ced by: ❑ Letter trom Veterans Administraoon or Departmem d Defense; or
❑ Oiscla�ge doaiments
C. ❑ The asussed vdluaaon (at 100°,6) of ihe property fa which ihe deduction is daimed (may nd ezceed 8763.000) S
D. ❑ The property is the applicanYS prindpal tesidence.
E. � The applicam ovmed fhe property (a was 6uyirg if urrder contract) fa at leasi one year beFOre the date of this application.
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