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APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS,
WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERANS
Slate Fwm 12662 (R6 / 10.07)
PresaiOeO by ihe Department of Local Govemment Finance
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�NSTRUCTIONS: Please check appropriale box(es) pertaining to tax deduction. (More than one 6ox may 6e checked; however, a surviving
spouse who receives a deduction unde� Section IV may not receive a deduction under Section 11.J
�G DATES: '
REAL PROPERTY: DURING THE 12 MONTHS BEFORE MAY 11 OF THE YEAR THE DEDUCTION- S-l'O�PPLY. ,.� T. �
MOBILE HOMES (&1.1-7): BETWEEN JANUARY 15 AMD MARCH 31 OF THE YEAR THE DEDUCTI � O E E F IVES :
❑ I Totalty disabled veteran (or veteran af least age 62 with atleast 10% disa6ility) or survrvin _pou�- t t tde ed'56�000
Complete seGions I, V and VL pC G7.1-72-14)
❑ II PaRialty se ice-conneGed disabled veteran OR suniving spouse
Complete se�Ta�s II, V and VI. (IC 6-1.1-12-13)
❑ III World War I Veteian - Not to exceed 59,000
Complete sedions III, V and VI. (IC 6-1.1-12-77.4)
❑ IV Surviving spouse of World War I Veteran - Not to exceed 59,000
Not to exceed $12,000 F E B t� ;; 2002
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Complete sections N, V, and VI. (IC Cr7.1-12-i6)
Name of appl' n t, middl , las� Date of.biAh (month, day, yea�
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Address (st2ef a�M numbe�, � an sta 'p c�-o7d County
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Appficant ( dces'I does not ) own property with ano r individual(s) besides spouse andlor another veteren. �/ %) Q
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This application is made for the purpose of obtaining $ dedudion 6om the assessed valuation of the folowing desuibed taxable
propefty, for the year 20_ � � �
T' g Dis �(dty, to , f n5h� ) Is the property in question: Parcel or Key number /.�1,_', n uC l�C-`
❑ Real Property ❑ Mobile Home pC 6-7.1-7) j� JUI/n
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� App6rant was a member o( the U.S. Artred Forces for at least 90 days (rat necessany durirg ivar tirtre).
B. 0 Applirant was horroraby d'�arged.
C. ❑ Apptipnt is: ❑ Totaly disabled; or
❑ At kast age 62 with al least 10°h disability
D. � ApptiranYs disabd"4y is evidenred by ❑ Certificate of eligibiliry from the Indiana Department of Vete2ns Afiairs;
❑ Pension certificate;
• ❑ Award of compensation Gom Veterens AdminisVation or Departrrent ot Defense; or
❑ Vete2ns Administration Fortn 20.5455'Tax Abatement Certifipte'
E. � The assessed valuation (at 100%) of ihe property for whirh the deduration is dairred (may not exceed 554,000) 8
F. ❑ Applinnt is the survrving spouse of an individual who would have qualified tor the dedudion under this sedion when he or she was alive. �
(Age o/deceased veteren on date ofdeafh 1
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A. ❑ Applipnt was a member of the U.S. Armed Forces during any of its wars. �
B. ❑ Applipnt was honorabty discharged. � •
C.�Applicant has a service-connected disability of at least 70°h
D. � AppliwnYs disability is evidenced by: �Certi(icate of eligibility hom the Indiana Departrnent of Veterens Affairs;
`❑� Pension cerlificate;
y� Award of compensation from Veterans AdminisUa6on or Department of Defense; or
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❑ Veterans Administretion Form 20.5455'Tax Abatement CeAificate'
E. O Applipnt is the surviving spouse of an individual who would have qualified for the deduction under this section when he or she was alive.
(Ageofdeceasedveteran�ondateo/death )
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A❑ App6caM is a vete2n oi World War L �
7 ApplicanYs d'isability is evidenoed by: ❑ Letter from Veterans Adminisvation or Departrnent of Defense; or
❑ Dscharge documents
C. � The assessed valuation (at 700°h) of the property for which the deduption is dauned (may not exceed 578.000� S�; � - . .' . _
D. � The properry is ihe applicanYs prindpal residence.
E. ❑ The appGCant owned the property (w was buyirg d under wn6acQ for at least one year before the date of this application. .
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