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Form Number 12A - Revised 1985 �
__PZescribed by State Board of Tax Commissionersmj`,{� �-� i
VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNEC��Y �
and Application for Deduction Fro�P�,� 6 1999
• Assessed Valuation of Taxable Property� n
* Qualificat�ions On Back �*** �J %�
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STATE OF INDI NA �? C�uN`I,Y� �Q �^/��( I
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(Name) �"— _ , being duly sworn on oath says
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��t (s)he is years of aqe; that (s)he resides at
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in County, Indiana; that (s) e
Check One: (� was a Member of the U.S. Armed�� ,'n f
its wars % g
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 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 $ 00 �
(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_����. ,L.L,�(D:=%- �'-'°��'$O
That, in addition to the above amount of S 00 deduction applied
for i his County, (s)he has or intends to apply for $ Q Q O deduction
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in County, Taxing District.
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� Subscribed and sworn to before me, and disability verified this � �
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day of , 19�.
~ Auditor