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CERTIFICATE OF ELIGIBILITY DISABLED VETERAN TAX DEDUCTION State Form 51186 (R5 / 11-13) DEPARTMENT OF VETERANS AFFAIRS 302 West Washington St. Indianapolis, IN 46204-2738 Telephone: (317) 232-3910 Fax: (317) 232-7721 * This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it. Name of veteran (last, first, middle) Date of Birth (month, day, year) Is the Veteran Deceased? Yes No Date of Death (month, day, year) Veteran’s Social Security Number * Veteran’s Service / Serial Number Veteran’s VA File Number Name of surviving spouse (last, first, middle) (Required only if veteran is deceased.) Telephone number E-mail address Property Mailing Address (number and street, city, state, and ZIP code) Mailing address where form to be sent if different than property (i.e. CVSO, County Auditor/Assessor) Signature of veteran / surviving spouse / authorized agent Date (month, day, year) In determining eligibility for the Disabled Veteran Tax Deduction benefit, the Indiana Department of Veterans’ Affairs (IDVA) verifies the veteran’s period of military service, United States Department of Veterans’ Affairs disability rating, and date of birth. The County Auditor will determine further eligibility for this benefit based on Indiana Code 6-1.1-12-13, 6-1.1- 12-14 or 6-1.1-12-15 and 6-6-5-5, 6-6-5-5.2. Once this form is complete with IDVA verification, it must be taken to the appropriate County Auditor for final determination of benefit and processing. FOR IDVA VERIFICATION ONLY Veteran’s beginning date of service (month, day, year) Veteran’s ending date of service (month, day, year) Type of service (check one) Wartime service Peacetime service VA disability rating Veteran’s date of birth (month, day, year) IDVA verification signature Date (month, day, year) For County Auditor Use Only Tax deduction amount Reset Form