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<br /> Ta�����EnW�TH Application for Exemption �o�M
<br /> from MatorVehicleTaxes
<br /> YoUR CouNTY by Qualifying Nonprofit Organizations (',5�
<br /> TFiEASURER •Read instructions on reverse side
<br /> ApplicanYs Name Cnunty Type of Ownership
<br /> EPWQRTH VYLLAGE INC A�LL �]Nor,protit
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<br /> Street or Othor Mailing Address Coun�y Numper Corporation
<br /> Z�1] � KR1]5�. _Aj1�. _ _ 4. LJ Other(specify):
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<br /> City State Zip Code State Where Incorporated
<br /> GRAND .T.SLAND NE 68803 NE - _
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<br /> Identify Officers,Directors,or Partners _..
<br /> T�� Name Address Cdy,State,Lip Code _ __ __
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<br /> LI57 SPECIFIC DESCRIPTIQN OFTHE MOTOR VEHICLES
<br /> •Attach addiYional sheet if necessary
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<br /> __. .-- -- - Registrafion fJate or Date
<br /> Vehicle Make Mpdel Year 8ody Type Vehir.le Identlficalion Number ot Acquisition ii Mewly
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<br /> Nature of Use of Motor Vehicle: Are the motor vehicles used
<br /> ❑Agricultural/Horticultural �ducational �ligious �Charitable ❑Cemetery
<br /> exclusively as indicated?
<br /> �' ° •.L�(YES �NO
<br /> �lailed description of use,i luding an explanation if multi le classifications exist: ..,__ '� _ ��
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<br /> Under pen�lties of law,I declare that I have examined this application and,ta the best of my knowledge d belief,it is cohf�llNT'�
<br /> omplete.I also declare that 1 am duly autharized to sign this exemption application,and that ihe organization own ng said prop�y�Ses`�E��������
<br /> G '.FF.P(D ISLhND,1�°EF3RASKA
<br /> discrimina[e in membership or employment 6ased on race,color,or national origin. ..,...T
<br /> sign �,'�1` c�•�-���'��'a ___.. _ <</�r/�
<br /> here Authorized Signature pate
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<br />'' FOR COUN7YTREASURER S FiECQMMENPATI�N
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<br />�� [�PPROVAL COMMENTS: ._��'�-�i-�S !�` �•�C�...._
<br /> L�DISAPPROVAL .. _
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<br /> 'Si nature of Count Treasurer Date
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<br /> FOR COUNTY 90A�iD OF EQUALIZATION USE ONLY
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<br /> ❑APPRDVAL C�MMENTS: — -----.
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<br /> �DISAPPROVAL � � �_ �..: .J� —_. � ` --..
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<br /> /Authonzed Signature / �ate
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<br /> Nebraska�epartment of Revenuo
<br /> -- - nucnor�zed by Nea.ae�.scat.§��-zoz(�)(c)(d�,§so-s,is�§so-s,ias
<br /> 96-?-53•2aD6 Rev.5-2009 SupersQdes 96-253�2006 Rev.17-2008
<br /> PLEASE MAKE A COPY FOR YqIJFi RECORDS
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