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2011
<br /> TOBEFIL�DWITH Application for Exemption FORM
<br /> YOUR CpuN7Y from Motor Vehide Taxes
<br /> TREASURER by Glualifying Nonprofit Organizations 457
<br /> •Read instructivns on reverse side
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<br /> Applicant's Name County Type of Ownership
<br /> HARVEST TIME BAPTIST CI{U1ZCF� __ . _ -- HAT.L _ _ _. �]Nonprofit
<br /> Street or Other Mailing Address Gvunty Number Corporation
<br /> 1125 N SEAL ST 40
<br /> _ ... ..._�_ __.. ...._..............._,.,.,.,.,._.,... �Other(specify):
<br /> Gjty StatQ Zip Code State Where Incorporated
<br /> GI2AND �SLAND NE b8$OI �. —T
<br /> � __ .. ..—. --- — � _.--
<br /> _.._
<br /> IdPntify O(ficors,Uirectors,or Parfn�rs
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<br /> _.... _
<br /> Title ,��� Name,Address,City,State,Zip Gode
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<br /> .W.;i i;�i•� !�' 4"— �- �i�.� ,L.r��� � �-A� _. �r��
<br /> 2,� ... � ..�G�r�.r r� i�`
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<br /> LI57"SPECIFIC DESCRIPTION OF7HE MOTQR VEHICLES
<br /> •Attach additional sheet if necessary
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<br /> --- - -"-"- Registratlon Date or Date
<br /> Vehicle Make Model vear Body Type Vehlcle Identific�ition Number v(Acquisiiion if Newly
<br /> _. ---•.._ ----- --...
<br /> Pur�h35ed
<br /> _ ,, —
<br /> �'i r +��-�.. . I ���.. �,� �- �"�,J��".s��7/�7/<y.�%�1
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<br /> --_'`,.._ J .., .�-._ .� .. .......... . .....,..__
<br /> ... _. _.... .. __ __......__. pre the motor v., ,....
<br /> Nature of Use of Motor Vehicle: ehicles used
<br /> �Agricultural/Horticultural �Educational �Reliyious �Charitable �Cemetery exclusively as indicated?
<br /> Give detaileU descriptibn of use,including an explanation if multiple classifications exist: �YES �NO
<br /> �i�lC ��' Gr'�'/?�L� 3�"�- C.�-`'1�-`�`�.�C",/3�fa � �O J7"h C-�ti�.,Y'c��1 _._._....
<br /> F If No,giv g� %
<br /> � r `T � �
<br /> / UN�/d NS
<br /> � G t" ; ;:� `_��J i0
<br /> com lete.1 alsoalties of law,I declare that I ha� �'
<br /> Under pen ve examined this application and,to the best of my knowledge and beliei,i(��r�4rt "an L�PFICE
<br /> p declare that I am duly authorized tn sign this exemption applicetion,and that the organization o ning sai�qper�y.,do'es;�,tit�„`,F�ASKA
<br /> discriminate in membership or employment based pn race,color,or national nrigin.
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<br /> s�g n �- j`/�°,/�Sc��!e�= ,�� ,,z./�c)
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<br /> here A� horize ignature Title Date
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<br /> �__ FOR COUNTYTREASUR�R'S REGOMMENDATION
<br /> �APPF�OVAL COMMENTS: �,/��--- ?�� �J"-�� ___
<br /> � DISAF'PROVAL —,,_.__ -- ---.._. _—_..._.
<br /> �:
<br /> �,���' � 1 � ).i � / ?..-��� r :;
<br /> '/�iy,., yti.r =�•��; I%-' e n. -•s ✓
<br /> ,Slgnature of County Treasurer Date
<br /> �..,.. _.� _, F�R _.._.. __.. .----
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<br /> COUNTY BOARD pF EnUALIZATION USE ONLY
<br /> ❑APPROVAL COMMENTS: __ _ ___..__.................�
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<br /> DISAPPROVAL f ' , ---- -------_.,.,.--�-.,_
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<br /> ACithorized Signature Pate
<br /> . Nebraska�epaYlment of Revenue � Authorizad by Neb.licv.SIaL§77-202(1)(C)(d),§GO-3,1(35§GD-3,189
<br /> 96-253-2006 Rov.5-2U09 Supersedes 96-253-2006 Rev.11-2Dp8
<br /> PL�ASE MAKE A COPY FOR YpUR RECORDS
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