Veterans_Williams (2)�
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Form Number 12A - Revised 197! ,j�(/
Pr•e�cribed by State Board of Ta C�bai ssioners�
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VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILI —� %
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STATE OF ZNDi N
(Name) �
that (s e 's
and Aoplication for Deduction From the
Assessed Valuation o: Taxable Property-
**• Qualifications On Bac'r. ***
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in
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he resides at
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worn on oath says
Cour:ty, Indiana;, th
Check One: �s a 1Nember o� �he �U.S. Armed Forces duriyg
its wars ��
or the widow of a member of the U.S. Armed Fo
who served during any of its wars
(s)he
any of
s
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. 1-12-1� 9�G ' y�� o
�py _ 3000
That this application is made for the purpose of obtaining $��
(not to exceed two thousand dollars) deduction from the assessed valu-
ation of the following described taxable property for the year 19 ��
to wit:
TAXING DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER( \ ��— —��
That, in addition to the above amount S deduction applied
for in this County, (s)he has or intends to apply for $ deduction
in County, �Taxing District.
_� Subscribed and sworn to before me,
' day of ��� , 19 p z
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ied this / �
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