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<br /> 7o s�F��Eti��T►� Application for Exemption FORM
<br /> from Motor Vehicle Taxes
<br /> YOUR coUNTY by Qualifying Nonprofit Organizations 457
<br /> 7REASURER •Read instructions an reverse side
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<br /> ApplicanYs Name County �ype of Ownership
<br /> CENT�;R FQR INDTPEI�TDENT L�VING ___ HAT.T, �Nonprofit
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<br /> Stroet or Other Mailing Address County Number Corporation
<br /> 320G COLLEG� ST �+� ___ ❑Other(specify):
<br /> Ciry State Zip Code StaTe Where Incorparated
<br /> GRAN17 ISLAND NE 68803 NE
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<br /> Identify Officers,DirPCtors,or Partners
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<br /> 7itle Name,Address,City,State,Zip Code
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<br /> ST 3P�CIFIC DESCRIPTION OFTHE MOT VEHICLES � �
<br /> •Attach additional sheet if necessary
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<br /> -- RegistraUon�ate or Dalc
<br /> Vehicle Make Model Year� eody Type Vehicle identific�tion Numher of Acquisition ii fVewly
<br /> Purchased
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<br /> Na�ure of Use of Motor Vehicle: Are the motor vehicles used
<br /> ❑Agricultural/Horticultural Educational ❑Religious �Charitable ❑Cemetery
<br /> exclusiveiy as indicated?
<br /> Give detailed description of use,including an explanation if multiple classifications exist: ��_C-�.. _,.._ �YES ❑NO
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<br /> _�-F..�P.r�I_L G�S _. .�] iv► c�.��.1��. �� �ry �.>�r � �� � ;.:.
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<br /> IJnder penalties of law,I deciare that I have examined this application and,to the best of my knowled and beliefr���g; t ,�
<br /> complete.I alsa declare that 1 em duly authorized to sign this exemption spplication,and that the organizatian ning sa�gt�qp���EY1
<br /> discriminate i�f+jembership or employment based on race,color,or_t]ationai origin. '�'"
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<br /> s i g n �,� ;� ,� �� �����f� . -�-� , �� ��� .� _. _. � ! ���- t.�
<br /> here ��orizQCrS�re�:' Title bate
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<br /> f `- .� FOR COUNTYTREASUR@R'S RECOMMENDATION
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<br /> �PPROVAL COMMENTS: ,/,,� �✓ --._J��,7�L�". _. _
<br /> �]DI5APPROVA� ------
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<br /> I Signature oi County Treasurer �ate
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<br /> FOR COUNTY BOARP OF EQUALIZATION U5E ONLY
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<br /> []API'ROVAL C�MMENTS: —_. -
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<br /> �DISAPPRQVAL ;;�'_ = ._� ' ' ` __.. .-- -... _
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<br /> I Authori ed Signature Date
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<br /> Nebraska�eparlment o1 Revenue Authonzed by Net�.Rev.5[at.§77•202(1)(c)(d).§6o-3,185§60-3,189
<br /> 96-25;�•2006 Rev.5-2009 Suparsedes�J6�253-2o0G Rev.17•2ooe
<br /> PLEASE MAK�A GOPY FbR YOUR RECORDS
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