- Hicks, David_8/24/2022 „7? rr Number 12A - Revised 1985 �� e �� �o��`ttki-
Prespribed by State Board of Tax Commissions
VETERANS, OR T W HEIR_ IDOWS, STATEMENT OF SERVICI _ ��l
( ` and Application for Deduction \-��
Assessed Valuation of Taxable
*** Qualifications On Bac
STATE OF INDIANA . P C_i_o l--.,-«-
(Name ) (13a/v-42_ b' bt- 000.
chat (s )he is years of age ;
that (s ) he C14\ 13�,q 2,0Z'-/-- �`�y��''�—
411scarn; 01_4,,u in �„�Y Cc -` ,
Check One : was a Member of the U. S . 1.-.<«' r c'rces curing any of
its wars
`667 ../ or the widow of a member of the U .S . Armed Forces
g, , cr �j3 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 Certificate or 2r _1z. _V j ^-'�f1. �'\C(7 Cr ,
Avtard of Compensation or LMJ CD .--Cr
L:Lc�
Veterans Administration Form 20-5455 "Tax Abatement Certificate” br
C�ett6r statement of ten percent disability or more from the
Department of the Defense Disability Retirement Board of the
appropriate branch of the armed forces .J_cGao2 40.l%1 /J
i t o r . X�!/t. �.�2p Ld '� 'P�
1. 1-12-13 and 6-1. 1-12-15 l
120
made for the purpose of obtaining $ ` 4XQ•�• i
kf\Q dollars) deduction from the assessed valu-
�� :ibed taxable property for the year 19 ,
___,___ ,v„v",„, .
r_z)
1B - 60
above amoun of $ deduction applied
_Ls or intends to apply for $ deduction
inAjii: County , .!Ni'M Taxing District.
X �2tr.
(Applicant/Guardian)
Subscribed and sworn to before me , and disability verified this p`
day of 19T5
CM .
Audi to