Veterans_JonesForm Number 12A - Revised 1977 � �'�9'�"��
P-rescribed by State Board of Tax Conmissioners -�j �
_ VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABTLITY ---"-'
� and Application for Deduction From the Q �5 Z/ 3 77�ii'�
Assessed Valuation of Taxable Property �/
•** Qualifications On BacY *** �f
STATE OF INDIANA �,�.d� COUNT.Y, SS:
-� `
(Name) �y.y� �.�a/ , being duly sworn on oath says
that (s)he is �3 years of age; that (s)he resides at �
in- ,ChA�.s�. County, Indiana; that (s)he
Check One: �(_ was a Member of the U.S. Armed Forces during any of
its wars
or the widow of a member of the U.S. Armed Forces
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: � Qu C�� �{.�
Pension Certificate or lOO �d � w�
Award of Compensation or
�_ Veterans Administration Form 20-5455 "Tax Abatement Certificate" or
Letter statement of ten percent disability o e r �
Department of the Defense Disability Retir en� �� � t6ie
appropriate branch of the armed forces �'" ��� �
exhibited to the County Aua�tor. ��A1' '� �i j`q•9(� _(� p pD
IC 6-1. 1-12-13 and 6-1. 1-12-15 � ����d
.�!� �.��.� .' 3 oaa
That this application is made for the purpose of o�taT�iing_;$
(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 of $ deduction=applied
for in this County, (s)he has or intends to apply for 5 -deduction
in County, Taxing District.
�/� �- C�-. �-� � -
(Ap ic nt/G rdian)
� Subscribed and sworn to before me, and disability verified this /•�('�
day of � �,� , 19�_ '
v `- `��
Auditor