Veterans_Widick_ 3 -
;Form Number 12A - Revised 1985 , 1`�''
`� Prescribed by State Board of Tax Commi�ssioners .- `,
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABi{�}�T�F q�� �
tU ` !� tl 1'
�� and Application for Deduction From the •�t 1S1i�
Assessed Valuation of Taxable Property ��u� 1 3 1993
. **+� Qualificat�ions On BacY. **'
STATE OF INDIANA _�(1� ��Q.(`/Y\ COUNTY, SS: �J p. i/ <
��� . �� 1_ �.�L AUDITOR�
(Name) 1 lienN\ .l /(� , being duly sworn on oat says
- (s)he is years of age; that (s)he resides at �
in �}�yv� County, Indiana; that (s)he
Check One: V was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S, Armed Forces
who served during any of its wars
and who has been honorably discharged there£rom and has a service-
connected disability of ten percent (10 percent) or more and is
entitled to this deduction as evidenced by: �_�_� ����
Pension Certificate or
��ward of Compensation or
eterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
Department of the Defense Disability Retiiement Board of the
�^ appropriate branch of the armed forces
���-��-�iibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $��
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19�,
TAXING.DISTRICT �� ,'�Gti� l/,�.CJ.dQ.
LEGAL DESCRIPTION OR KEY NUMBER �.1A0� XA� _
That, in addition to the above amount of $�iu _ deduction applied
for in this County, (s)he has or intends to apply for $�� deduction
in ��AXi�M _ County, —�Taxing District.
X ��� —� l
.� (Applicant/Guardian)
-,�, )'Subscribed and sworn to before me, and disability verified this �
- :ay of � . 19�.
�
a ,�.,,�o � �, ��„
Auditor
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