Veterans_Williams (4)APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERi4NS, �����
� W1NI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
.^ . StateForm12662(R71/10-08) e ��
� ,. Presaibed by lhe Departmeril d Lopl Govemment Firw�m � � '.
FEB 2'2 2011 •
�STRUCTIONS: Please check appropriate box(es) perfainim� to tax deduction. (More than one box may be checked,� however, a surviving
spouse who receives a deduttion under Sec6'on IV may not receive a deduction under Section 11� � n`y��.�
FILING DATES: � �
REAL PROPERTY: DURING THE YEAR FOR WHICH THE DEDUCTION IS SOUGHT. J v
MOBILE HOMES (IC E1.1-7) OR MANUFACTURED HOMES NOTASSESSEDAS REAL PROPERTY: DURII���§�(,d��j(�j1�o�p��pp�s
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTION.
� I �TOtalty disabled veteran (or vete�an af leasf ege 62 wifh af least f� dise6ifity) or surv'rving spouse
Complete sections I, V antl VI. (IC &7.1-12-14)
� II Partialty service-mnnected EisaWed veieran OR wrirving spouse - Not to exceed 524,960 /
Complete sections 11, V and VI. (IC fi1.1-12-13) j
❑ 111 WoAd War I Veteren - Not to exceeE 518,720 �
Canplete sections III, V antl VL (IC G1.1-72-17.4)
❑ N Survivinq spouse of Wwld War t Vetaran - Not to exceed 518,720
Not to exceed
�,sG�v C�
Complete sections N, V, and VI. (IC 61.1-12-i6)
G� )
Name of applicant (fvst, middle, las� .
�� ��
AtlCress (56eet end num6er, city, sNdte, arM ZIP oode) Coun
/ �H ToN C T'�a � - .v Y-7G o �'! so
Applkent Qdoes Qdoes not ) own property with another intlivi0ual(s) besides spouse antl/or anoNer veteran.
d
This applicatiwi is made for the purpose of obtaining S�� `7� Y/% � deduction from Ihe assessed valuafion of Ne (ollowing described taxabie
property fa the year 20_
Ta�drg District (dty, town, township) Is the property in Questlon: Parcel or Key num�er
❑ Real Property ❑ Mobile Home (IC 6-1.1-7)
• � • • i'
�� AppGrant was a manber of Ne U.S. Artned Faces for at IPast 90 days (rrot necessany duiv'g �ra�6me).
B. � APP6cant was honasdy tlischart�ed.
C. � App6raM Ls: ❑ TotaOy d�sa�led: or
[� At least age Q with at I�si 1�96 disabiGty
o. � Ma��rs dsab�H s evid�d by ID Certificate a( dgibiGty from the Ind'ana Departri�ent of Ve�e2ns ARairs;
❑ Pension certfirate;
❑ Awafd of compensatim from Veterans Administratim or Departrnerd of Defense; w
❑ Veterans Mministrati�on Fortn Z(Y5455 "fau Abatement CeAficate'
E. Q The assessed vaWation (at 10096) ot tha property far whidi fhe tletluction is daimed (mayrrot exceed $143,160j S
F. �{ Appfirant is Ne siwivin9 spouse of an mdividual vRqa Id have qualified for the dedudion untler Nis sectlon when he or she vras alive.
(Age d deceased veteran on date d deeth /� )
. . . .
A� Applicant was a member of the U.S. Armed Forces during any of its wars.
B. � Applicant was honwably discharged.
C. [� Applinm has a seMce connected disability of at least 10%
D. � P.ppGnnYs disabiliy is evidenced by � Certifrcate of eligibiliry Gom ihe lixliana Department of Veterans ARairs;
❑ Pension certifirate;
❑ Award ot compe�safion fran Veterans Administrafion w Department of Defense; or
❑ Veterans Administration Form ZO-5455 Tax Abatement CertiScate
E. �Applirant is the surirving spouse of an individual who xrouid have qualified for �he deduction under this sec[ion when he w she was alive.
(Age o! deceasetl veteran ar date W death 93 )
.
A QApp&ant is a veteran of World War I.
B. QAppfiraM's service is aridenced by ❑ Letter from Veterare Adrtdnisiration or Departrnent � Defense; or
❑ Diuiwgedocuments
'. � ma �sessea �wano„ (ar ioox) or u,a a�oaenv ror wrom u,e aeauao�, s aamed (.r,ay r�or a:o�d s2oa,soo� s
D. Q The pmpety "s the appficaM's prnxipal residence.
E. QThe app5cani avned the pmperty (or wes buy'mg it uMer oon6ac� Tor af least one year befora the date of this app&ation.
• . • � _
A.❑Applicant is the surviving spouse of an individual who served in the U.S.Armed Forces before November 12,1918. Ask,—
B.
❑ The service of the deceased spouse is evidenced by: ❑ Letter from the Veterans Administration or the Department of Defense;or
❑ Honorable discharge documents
C.❑ The deceased spouse received an honorable discharge.
,"4.ir"SECTION�V. -Additional Information.g -,_.;�,£k,.'t✓ i,'y�-..:� _ 3-1_:. -�--:
A.❑Applicant owns the property on which the deduction is claimed or is buying it under contract that provides that the applicant is to pay the property taxes.
which contract,or a memorandum of the contract,is recorded in the County Recorder's office. Record number page
B. ❑Applicant has applied or intends to apply for one or more of these deductions on other property in this county or in another county.
0 Yes ❑ No Amount S
County Taxing district
Second county Taxing district
gSECTION Ark:,Ajiplicalhon VcriTication and;'Audilor Signature;4,1a-i=}.,'<G ,7A.+:�1Kgn'��...-':T.
I certify that this application was filed in my office.
I certify that the information provided in this application is true and Date filed(month,clay,year)
correct.The intentional inclusion of false information on this form is QtR/4 A /a.p//
a criminal violation under IC 6-1.1-37-3 or 4. Signature of county auditor
Sr of applicant legef representative Name of county auditor(typed or written)
, ,rfnu4.4.4 C V S o
.? 5. - zw_ S'.i�,,?"-3k ae`•'�•a` '` �.' -•..'•'"VETERANi DEDUCTION:WORKSHEET& ?" cam:
20 20 20
1. Total Disabtity($12,480)
2. Partial disability($24,960)
3. WWI Veteran($18,720)
4. WWI surviving spouse(S18.720)
5. Total deduction available(add lines 1, 2,3 and 4)
6. Amount applied to real estate key number
7. Amount applied to personal property duplicate number
8. Amount applied to mobile home duplicate number
9. Total deduction applied to taxable property(add lines 6, 7 and 8)
10. Deduction available for excise-(subtract line 9 from line 5)
11. Excise credit
'May be used as an excise tax credit on either the Motor Vehicle Tax(IC 6-6-5-5)or Aircraft License Excise Tax(IC 6-6-6.5-131
calculated at$2.00 per$100.00 for cars and for aircraft[see 6-6-6.5-13(e)] of unused veteran's deduction.
The information contained on this form is CONFIDENTIAL according to IC 6-1.1-35-9.
•
ri-
-' DEPARTMENT OF VETERANS AFFAIRS
� 1�- CERTIFICATE OF ELIGIBILITY E ED 302 West Wahl g an S1.
,lir . DISABLED VETERAN TAX DEDUCTION RED ndianapo0s,IN a82042738
Telephone:(317)232-3910 .
<: - Stine Form 51106(R3 r ate) 10�� Far(317)232-7721
® FE81 -1 •
• This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1;
disclosure is mandatory and this record cannot be processed without It
Please take this approved form to your county auditor's office no later than December 31. If you am using this on your excise tax,you
must first submit the approved form to the auditor's offers, who will then Issue you an excise tax receipt to take to your local AMv.
Name of veteran(last first,middle)
VIII LL 111AI S C7 IL EN N A L[_EN
Name of surviving spouse past first middle)(Required only if veteran is deceased)
N/cL_LANIs A,-/ce M 4E
Social Security Number of surviving spouse' -
333 -I? -/G 72.
4111 Property Mailing Address(number and street, city, state,and ZIP code)
a//0 4cchfro/V (1-et, ,2r 4-Pr /0 /42/NC eraAl I/(/, 1F74. 20
Mailing address wheform to be sent if different than property(i.e.CVSO,County Auditor/Assessor)
G185oN Cr.:. VETCR-,4n/S SERV/cg OF (ce
,7a<s Azf/.¢,er ST, P k t AlcE i o,(/ mN, ‘)‘-76 70
Signatu of veteran I surviving spouse I authorized agent Date(month,day,year)
°—Sr i; CVS0 a////,-76,44/
(
®- -
2/I 'd T2LL2£2LT£:01 82b£S8£2T8 WOO OD NOSSI9:WOJd £T :2T IT02-IT-