Veterans_Hix (3)Form Number 12A - R"evised 1985
'Prescribed by State Boazd of Tax Commissioners
� ` �VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISAB�Y�����
.4
: and Application for Deduct�i�on From tne � DEC 2$1995
Assessed Valuation of Taxable Property
*** Rualificat�ions On BacY. *•' n ,L
LGyvr,ttJ �o
STATE OF ZNDIANA
S
COUNTY, SS:. AUDITOR
(Name) Q , being duly sworn on oath says
`-ha (s)he is years of ge; that (s)he resides at Q,.Q.��dX.��g�
in 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:
PenSion C2Tti£1CdtE 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 $�
�o _
(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 DESCRIPTIO
�
L_J
!,' .b
That, in addition to the above amount of $ v00. deduction applied
for in this County, (s)he has or int s to apply for $� deduction
in County, Taxing District.
� X �'i/%/I;�. � �'�o
A pl c t uar 'an�
Subscribed and sworn to before me, and disability verified this �
day of �� , 191> .
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W �/�'+- � ' �
Auditor '-
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