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Form Number 12A - Revised 1985 �
-__Prescribed b State Board of Tax Commissioners �-��
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CO� ,�fD`�DiS�A�Y . 4 �
and Application for Deduction Fro�AP�,,� 6 1999
• Assessed Valuation of Taxable Property� �
* Qualificat�ions On BacY. *** �j . r
. �+ �i � �
�iRC_n�N C,J' 7Y .AUDI{'•�q
STATE OF INDI NA C�VyTY. �{�
- � �o ��J�aS �
(Name) r" - , being duly sworn on oath says
4 , . - . • � /�oiC�r- / ' i r°°"o
��t (s)he is years of age; that (s)he resides at °f{%�—
(
in County, CIndiana; that (s) e
Check One: (� Was a Member of the U.S. Armed �f� 'n f
its wars % $
or the widow of a member of the U.S. Armed Fo c'e� �
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 aoard 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 $ QQ �
(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 DISTRICT
LEGAL DESCRIPTION OR KEY NUMBER O_�~Q ��0-� (Qa--y� �O�O
That, in addition to the above amount of $ �Q deduction applied
for i his County, (s)he has or intends to apply for S Q Q O deduction
. �
in County, Taxing District.
. r
� � leipp�icanc��va�— c
� Subscribed and sworn to before me, and disability verified this � '
day of , 19�. +
/_. _�✓ � /���`��M/ '\
` / Auditor