Veterans_Shanks,FOrm Number 12A - R"evised 1985
Prescribed by State Board of Tax Commissioners
� �
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABI
: and Application for Deduction From the
Assessed Valuation of Taxable Property �
**• �ualifications On BacY, ***
STATE OF INDZANA ��(�(,J�CJ�/rl COUNTY, SS:
v
��� - 3199�
(Name) {�i1 �L�1$.y� , being duly sw�'rLn�n�oa�th��ays
-� AUDITO
�hat (s)he is
��Check One:
\'
years of age; that (s)he resides at 0 �
in �/���/ N County, Indiana; that (s)he
`1��I �6 �-�o�
was a Pfember of the U.S. Armed Forces uring any of
ts wars
or the widow of a member of the 0.5. Armed Forces
who served during any of its wars
and who has been honorably discharged therefrom 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
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
That this application is made for the purpose of obtaining $y�
(not to exceed four thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 1995,
to wit:
TAXING DISTRICT
LEGAL DESCRIPTIO
That, in addition to the above amount of S deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, Taxing District.
X
pp icant/Guardian)
��j �
Subscribed and sworn to before me, and disability verified this
day of ���m„�. _ _, 19! �
�J�,�.. o �
Auditor
e