Veterans_Bennett APPLICATION FOR TAX DEDUCTION FOR DISABLED VETERANS
t , AND SURVIVING SPOUSES OF CERTAIN VETERANS
State Form 12662(R16/1-17)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: Please check appropriate box(es)pertaining to tax deduction.(More than one(1)box may be checked;however,a surviving spouse who
receives a deduction under Section III may not receive a deduction under Section II.)
FILING DATES:
REAL PROPERTY: FORM MUST BE COMPLETED AND SIGNED BY DECEMBER 31 AND FILED OR POSTMARKED BY THE FOLLOWING JANUARY 5.
MOBILE HOMES(IC 6-1.1-7)OR MANUFACTURED HOMES NOT ASSESSED AS REAL PROPERTY:DURING THE TWELVE(12)MONTHS BEFORE
MARCH 31 OF EACH YEAR FOR WHICH THE INDIVIDUAL WISHES TO OBTAIN THE DEDUCTION.
FILE WITH THE COUNTY AUDITOR OF THE COUNTY WHERE THE PROPERTY IS LOCATED.
❑ I Totally disabled veteran(or veteran at least age 62 with at least 10%disability)or surviving spouse-Not to exceed$12,480
Complete sections I,V and VI. (IC 6-1.1-12-14)
❑ II Partially service-connected disabled veteran or surviving spouse-Not to exceed$24,960
Complete sections II,V and VI. (IC 6-1.1-12-13)
❑ III Surviving spouse of World War I Veteran-Not to exceed$18,720
Complete sections III,V,and VI. (IC 6-1.1-12-16)
❑ IV Deduction for homestead donated to veteran ��—
Complete Sections IV,V.and VI. (IC 6-1.1-12-14.5)
Name of applicant(first,middle fast) Date of birth month,day,year)
m, 1. IR `- e.r�c� -a - c` t 1.- l91 lstto.
Address/number and street,city,state,and IP del_ Coun
t0 0 ., '—N � -t.-1 Leit bScz.,r
Applicant (❑ does Nrdoes not) own property with another individual(s)besides spouse and/or another veteran.
This application is made for the purpose of obtaining$ ,�� g‘...ctO deduction from the assessed valuation.of the following described taxable
property for the year 20 . (If applicant desires that deduction be split among additional properties,list those properties on additional sheet and attach
it to this application.)
Ta 'ng District(city,town,township) Is the p erty in question: Parcel or Key number
1 a Ilk —A LW F:eal Property ❑ Mobile Home(IC 6-1.1-7) j+—{I—' P 0O "A. .$ -•Qo��
SECTION I - TOTAL DISABILITY OR AT LEAST AGE 62 WITH AT LEAST 10%DISA'.ii.,TY 471)
nt was a member of the U.S.Armed Forces for at least ninety(90)days(not necessarily during war time).
B. �a cant was honorably discharged. F�
C.rrpplicant is: ❑ otall disabled;or
t lea ge 62 with at le 10°°disability 2042
D.❑ Applicant's disability is evidenced by: cote of eligibility from the Indiana Department of V, irs;
Pension certificate; O NCO �'
❑Award of compensation from Veterans Administration or Department cfeil feri"s
❑Veterans Administration Fom120-5455"Tax Abatement Certificate" AVO/r
E,❑ The assessed value of the applicant's Indiana real property,Indiana mobile home not assessed as real property,and Indiana manufactured home not
assessed as real property does not exceed$175,000. Deductions claimed$
F. ❑ Applicant is the surviving spouse of an individual who would have qualified for the deduction under this section when he or she was alive.
(Age of deceased veteran on date of death )
SECTION II - PARTIAL DISABILITY
A.07 P�pplicant was a member of the U.S.Armed Forces during any of its wars.
B.,. Applicant was honorably discharged.
C.E Applicant has a service connected disabilityof at1l tst 10%
D.0 Applicant's disability is evidenced by: r ertificate of eligibility from the Indiana Department of Veterans Affairs;
❑ Pension certificate;
❑ Award of compensation from Veterans Administration or Department of Defense;or
❑ Veterans Administration Form 20-5455"Tax Abatement Certificate"
E.❑ Applicant is the surviving spouse of an individual who would have qualified for the deduction under this section when he or she was alive.
(Age of deceased veteran on date of death
SECTION III - SURVIVING SPOUSE OF A WORLD WAR I
A.❑ Applicant is the surviving spouse of an individual who served in the U.S.Armed Forces before November 12,1918.
B.❑ The service of the deceased spouse is evidenced by: ❑ Letter from the Veterans Administration or the Department of Defense;or
❑ Honorable discharge documents
C.❑ The deceased spouse received an honorable discharge.
A person may not claim this deduction in conjunction with the partially disabled veteran deduction.
SECTIONS IV,V,AND VI ARE ON REVERSE SIDE
Page 1 of 2