Veterans_Pegram' •Form Number 12A - Revised 1985 � n
Prescribed by State Board of Tax Commissioners �-�
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED IT��
�� and Application for Deduction From the�� � 19°�5
�� Assessed Valuation of Taxable Property �Q� ��� '" '�
. **• Qualifications On BacY, *** ryWy-��
V
STATE OF INDIANA GI ��SO'V COUNTY, S5�/1"" PVO\�OR
/� � � �
(Name) . L�/���I� f'Pc.��O�lv1 , being duly sworn- o�i� s.�
T
thaCt (s)he is � years of age; that (s)he resides at �
41,��� •�' i ___ G)�S(5� County, ian�hth (s)he
L -�
Check One: � was a Member of the U.S. Arm�OF sces ing any of
its wars �
or the widow of a member of the .S. Arme ces`�7 6
who served during a�y of its wars�r �� ��
�� yc/p W LILI� ��
and who has been honorably discharged therefrom and has a service-
connected disability of ten percent (10 percent) or more and� '�
entitled to this deduction as evidenced by: 3
Pension Certificate or ' � � �+� �
� Award of Compensation or
Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability or more from the
Department of the Defense Disability Retirement Board of the
� appropriate branch of the armed forces
exhibited to the County Auditor.
IC 6-1. 1-12-13 and 6-1. 1-12-15 °s y9�i�
{�'ed
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 \� ,
to wit:
TAXING DZSTRICT �
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $� deduction applied
for in this County, (s)he has or intends to apply for $ — deduction
in County, — Taxing District.
X ` � ��.
.'.�, (A 1' cant/G rdian)
�` .
Subscribed and sworn to before me, and disability verified this
day of 1 Qtr \� . 19q�J•
Qnn ,-.-... 1� 1`�l1 c. n t�
Auditor
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