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<br /> 2011
<br /> TpB�FILEDWITH Application for E�cemption �o�M
<br /> from Motor Vehicle 7axes
<br /> YOUFi COUNTY py Aualitying Nonprofit Organizatians ,4��
<br /> TREASLI flER •Read instructivns on reverse side .,, ___,
<br /> AppliCant's Name � �� mm �� County Type ot Ownership
<br /> GIRL$ SCOUTS — SPIRIT UF NEBRA.SKA �1• ____ _ �Nonpratit
<br /> 5lreet nr Other Mailing Address Counry Number Corporation
<br /> 240q WTLDWOOD DR _.._ 4q ❑Other(speciTy):
<br /> ��h, "'—"" � � State Zip Code State Wh6re Incorporated
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<br /> ��1� ��JT^ANT9 NE ,� 688_ .E.....__..._._ �..,.__. - �
<br /> _ . _..._ .._. _, _�._.._____.._._.�
<br /> Identify OPficers,Directors,or Partners
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<br /> Title � T Name,Address,City,State,Zip Cnde __�.._.x_
<br /> _.__ _ .._ _... h -_C�,��v_.�cti,���/ (ti' � ; .� __m �!_.._(� �a� _._..._.._
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<br /> f � LIS"f SPECIFIC DESGRIP710N OFTHE MOTQR VEHICLES �
<br /> I � Y •Attach additional sheet if necessary
<br /> L—.�—�� RBgfstration bate or Date
<br /> VehicleMake ModelYear 8ody7ype VehicleldentificationNumber niAcquisition'rfNewly
<br /> Purchased
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<br /> Nature of Use of Motor Vehicle: Are the mator vehides used
<br /> r-�Reli ious Charitable Cemete exclusively as indicated?
<br /> ❑Agr'�cultural/Horticulturat �Educatianal �I 9 � ❑ �'
<br /> Giva detailed desCription of use,including an explanaTwn if mWtipie dassifications exist: � � v.`-1(1� �� �YES �NO
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<br /> ��'�� llnder penaKies of�w,1 deciare that 1 have examined this applicalion and,to the best of my knowledge nd haliet,it is correct�d�NTY
<br /> coroplete.I also deciare that I am duly autharized to stgn this exemptlon application,and that the organization o ing said prc���E=RS pFFIC�
<br /> discrimina � membership ar employment based on race,color,or nstional Origin. GftANC7;4;!_qND,NEF3f�l�Sl{A
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<br /> sign � __�r,�—���� __ � a�� ,� � /� /c ,_.��G�
<br /> h�1i�" uthonzed Signature Title Date
<br /> � � �� �QR COLJNTY TREASURER'S RECOMMENDATIDN -- _ __.�
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<br /> �/ 'c� r�l ___
<br /> [G�APPROVAL COMM�NTS: -�---.-..
<br /> []DISAPPROVAL �"'�--
<br /> � � ��//'���L, _ . ......_......._ �s�J-a /�//7� _
<br /> Signature pt County Treasurer Date
<br /> � � FOR COUNTY BQARD OF EQUALIZA7IDN 1,15E ONLY ��T��
<br /> ❑APPROVAL COMMEN75: __.._ ..... .�J..__....... .._._
<br /> ❑OISAPPROVAL _._ _, � � � � _...� �___�
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<br /> �Aut on ed 5 nalure �al�
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