Veterans_Dosett (2)�
Form Number 12A - Revised 1985
Prescribed by State Board of Tax Commissioners
�
;,:� -
� VETERANS, OR THEIR WIDOWS, STATEMENT OF SERVICE-CONNECTED DISABILITY
�- .
and Application for Deduction From the
.� Assessed Valuation of Taxable Property
**+� Q alificat�ions On BacY. •**
STATE OF IN IANA �p{ �
(Name) , bei9l.g�u1'y��� rn on oath says
� �� 200�1
�hat (s)he is _� years of age; that (s)he re e at
in � C nty �'�i�O �at (s)he
OL � Y
Check One: was a Member of the U.S. ����`,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:
�ension 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 Hoard 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 $�
(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 NOMBER �/6 -b0�59 -b0
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $�7 deduction
in ��p�-L— County, Taxing District.
X �
(Applicant/Guardian)
� Subscribed and sworn to before me, and disability verified this �-
day of , ���
Auditor