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2011 <br /> TO�uVITM Application for Exemption FORM <br /> YOUR CpUNTY from Motor VehicleTaxes <br /> 'rREASURER by Qualifying Nonprofit Organizations A�� <br /> •Read instructions on reverse side `F <br /> _........_.— .._.,_ ...---- _,_ _ __..— _ _._..,_... <br /> Applicant's Name County Type ot Ownership <br /> iJI�dTX C/0 SENIOR CITI'CENS INDUSTRIES INC_.. �]Nonprotit <br /> Street or OtheZr�Ma li0n <br /> g Address County Number Corporation <br /> 304 E 3RD ST 4Q <br /> ..-- ----.___..__.._-- <br /> City � State Zip Code State Where Incorporated _ Other(specify): <br /> ��rm YsLnrm ra� bssol �y� �-- <br /> .. __-� _. _..-- - ..._ <br /> Idenh ORicers Direcfors,vr Partners - <br /> � ---- y P ._ __ _. _ _. <br /> 7iile Name,Address Ci1 State Zi C <br /> ode J <br /> _....._..... --'._._.......................... ..._.,..T <br /> _ __.— ... LIST SPECIFIC DESCRIpTION OF THE M - - � <br /> OTOR VEHICLES <br /> •Attach additinnal sheet ii necessary <br /> -- -..,.. .._ -- <br /> Regisiration fJete'or Date <br /> Vehicle Make Modrl Year Body Type Vehicle Identification Number of Acquisition iF Newly <br /> Purchased <br /> - _._..._.. <br /> ----— <br /> � _.. __ <br /> _ ... .. . _. <br /> ----- —-_.....� --- _.....,.. _.... . <br /> _ . _. _ _.... <br /> Nature of Use of Motor Vehicle: Are the mator vehieles used <br /> �AgricuHural/Horticultural �Educational �Reliyious �Charitable �Cemetery �xclusively as indicated? <br /> Give detailed description of use,including an explanation if multiple classiiications exisi: YES �NO <br /> -\ , �......�� <br /> ' r�t 1�C�e s j��1�c�r�J�r�-s��c'�`��or�. C)—� `t'"1 \� ir No,s '�������;��°� <br /> e�e.r1� ,�i^�.��--p�. cc�md. �n��.�u.b1�e.. <br /> t�����n ��j.�..�. �o u x�z-� f��t� i 9 201Q <br /> H�,F_�courvTv <br /> _._..�....__ .._ T._ �..,_ �- -- •-- Z'.*:-;�=�,;�=.���=�,�� <br /> Under penalties of law,I declare that I have examined this application and,to the best of my knowleqg and be��#�`�q��r�,�f�an��g��S�� <br /> complete.1 also declare that I am duly authorized to sign this exemption applicatipn,and that the vrganization �-� <br /> discriminate in membership ar employment based on race,color,or national origin. <br /> sign ` <br /> � <br /> I/—/�-�� <br /> here �. ,pr�7ed S�g�atur� ...._. _.._ .� oa,� _ ._ <br /> r�r�e <br /> ... ----- _ _. _..._ <br /> -� <br /> FQR COUNTYTREASURER'S RECOMMENDATIpN <br /> ---- -._---.,..__— _,. -— _. _._.----- .. _..._ —. _ _,._ <br /> , <br /> "�APPROVAL COMMENTS: —.����_f��� Y-�-��.� <br /> �DISAPPROVAL ,___ <br /> _.__. ,.... <br /> . -- <br /> � � <br /> z�'-2�.����/�.J' ��--/�-/$, <br /> _ _ _. .. <br /> Siynature of County Treasurer Date <br /> ....._ _... __ --.,._ _._ _. . ..... <br /> _. _._ <br /> Y BOARD OF EOUALIZATION USE pNLY <br /> ....,.__ FOR COUNT _ _---- _. <br /> . .._� <br /> �APPROVAI. COMMENTS: —_.,,.__ _ , _ <br /> � ..,.. ,...— <br /> -� <br /> � DISAPPROVAL �__._m__.,__. f ' � � <br /> , - • -./�....._._ _,._. <br /> � \,- . .. _. <br /> r <br /> Authorized Signature � Date <br /> ___._..�...m...`_ _ __.. ._._._�.._ _ _w ...._ _.. <br /> Nebraska Aeparhnent of Revenue Aumorized by Neb.Rev.StaL§77•2p2(1)(c)(d),§60-3,165§60-3,78�+ <br /> 9Fi-253-2006 Rev.5•2009 Supersedos 9G�253-2006 Rev,11-2D08 <br /> PLEASE MAKE A GOPY FOR YQUR R�CORDS <br />