Veterans_GardnerAPPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS, �j ����
� WINI VETERANS AND SURVIVING SPOUSES OF CERTAIN VETERAIVfi
state F«m �2ss2lR�i i to oe)
S � Prasaihed by lha OepaAmeM of Loml Gwamment Finance J UN 2 S 2011
TJSTRUCTIONS: Please check appropriale box(es) pertaining to tax deduction. (More than one box may be�i�cked� oweve�, a surviving
spouse who receives a deduction under Seclion IV may not receive a deduction under Sectidr�qY�
FILING DATES:
MOBI ER OMES (ICDG-1R1 7) OR MANUFACO URED HOMES NOTAS ESSED AS RHEAL PROPERTY: WF21NG� HE TWELVE�(��IONTHS
BEFORE MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTION.
� I Totalty disabled veteran (or veteran at leest age 62 with at least 70% disability) or surirving spouse - Not to exce 12 480
Complete sections I, V antl VL (IC 61.1-12-14)
� II Partially service-connected Aisabied veteran OR s�rviving spouse - Not to exceed 524.960 \\� ��
Complete sections II, V and VI. (IC Et.'I-12-'13)
❑ III World War I Veteran - Not fo exceed 518,720 �
Canplete sections III, V and VL QC 61.1-12-17.4)
❑ N Surviving spouse of World War I Veteran - Not to exceed SiB,720
Complete sections N, V, and VI. (IC 61.1-12-16)
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Name of applicant (first, middle, las�
Address(s6eetandnumber, ' ,state,arMLPcode) County
lP/ 5, fFc=E — ! i v�V .Z /. (07 G BSo
Applicant Qdoes �foes not ) own property with another "uWivitluai(s) besidw spouse analor another veteran.
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Tiiis application is made for Ne purpose of abtaining S� i 9�i 0. � tleduction from the assessed valuation of fhe foDowing described ta�able
praperty fw the year 20
Tazing District (city, town, tnwnship) Is the property in question: Parcel w Key number .
❑ Real Property ❑ Mobile Hwne QC 6-1.1-7)
.: . • .. � .. �•. -. ... . -. i�.�.
�❑ P�pp6cant was a melnber of fhe U.S. Artned Forces for at least 90 days (rrof newssanly dur'vg �rdrtime�
B. ❑ APP6rant xas honora6ly dtsdia�ged.
C. O AppGraM is: ❑ TotaAy disabled: or
❑ At least ape 62 with at I�st 10% disabi6ly
D. ❑ Ap{�fianYs dsabSty a evidenced by ❑ CerO��`'rate of digibiGty (rom Me Ind'ena DepaMient of Vete2ns Affairs;
❑ Pensimcertikafe:
❑ Awaid of arnpensation from Veterans Admmistration or Departrnent of Defense: w
❑ Ve,erans Adrtrinistration Form 265455 Taz Abatemait Certificate'
E. ❑ The assessed valuation (at 10096) of �he properry for wftich Ue deduclion is clairtied (may rrd exceed 8143,16� S
F. ❑ AppGcant is tt�e swvivinc� spouse M an uWividual who vrould have quaGfied fw ihe dedudion undar iha sedion whs� he w she vras alive.
(Age d deoeased �steian on date d death )
. . � .
A�Applicant was a member of the U.S. Armed Forces durirg any of its wars.
B. �Applicant was honorably discharged.
C. � Applicant has a seMce connected disabiliry1oy�f at least 10%
D. j] AppiitanYs disabiliy is eviCenced by ,cx Certifi�ate of eligibiliry from Ne Indiana Department of Veterans ARairs;
❑ Pensbn certificate;
❑ Award of compensatlon from Veterans Administrabon w Departrnent of Defense; w
❑ Veterans Administration Form 20.5455 "Tax Abatement Certificate
E. Q Applirani is Ne surviving spouse of an individual who wvuld have qualified for the deduc[bn under this section when he w she was alive.
(Age W deceased veferan m dafe o/ death )
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A❑App6canf s a vetaan of WoM War I.
B. ❑App6caM's service is evidenced by ❑ Letter from Veterans Adrtmi¢Iration a Departmeni of Defa�sa; w
❑ Diuharge tlocuments
��. � ma ass�ed �mawo �a� �oos6) of a,e v�oaertv ror �d, me dea�o;o� s aar�e (mar „or er�d szos,soQj s
o. p me P� a u,e �vu�,rs P�i �a�.
E. ❑The appficant awned fhe pmperiy (w xas buying if imder wn6ac� fw at least me year before Me date oF tha app5ration.
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