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<br /> To B�DWITH Application for Exemption FORM
<br /> YOUR COUNTY frnm MotarVehicleTaxes
<br /> TREASURER by Qualifying Nonprofit Organizations 457
<br /> •Rcad instructions on reverse side
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<br /> Applic��var�INS C�NTER FOR BEI3AVIORAL HF.AI,TH CARE S�:R���ES coAATy�, Type of Ownership
<br /> Street or Other Mailin Address � Count Numbe �Nonprofit
<br /> g y r Corporation
<br /> �1� � �� S� �� BdX �.7E)3 __.._.,....... �Other(specify):
<br /> _.__ ,.... .,..__._.
<br /> City State Zip Code Staie Where Incorporated
<br /> RANI] T
<br /> 6LAND NE 68802 N�.
<br /> _. . .._..__ _. ...._-- m,._. _.--... __. .-- —.- ---
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<br /> IdentiTy�fficers,Directors,or Partners
<br /> Title NamE,Addr,,_. .......� _...
<br /> . ..,... . ., ...
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<br /> ess City,State Zip Code
<br /> _.. . _
<br /> Pr�s�c7e�t /GEO _ 5c� D.���_w_�r��.4 X.,�� e�G?.._D_r;� ���n� z�1Rn�� N� l���n
<br /> U�ce--Pr�s�c����+ /CFU _..----- .���( K;.���3 1:,�. !��`Sr�ee�- , Gr�nc� z•,itind�.N�,..E43�i
<br /> v���- i�r�,����� / c_ov --_._
<br /> �afw l���-�K , �c�x -7c� ; ..��ti r kS �� (�J�va� ---.. _.-----
<br /> �'�� �7'�h;cl,eci 1;5t d� ��� __.. ...,.
<br /> A. .--- _. -- -- ---... , ----
<br /> IC D�SCRIPTION pF THE MOT�R VEHICLES
<br /> ttaCh additional sheet if necessary
<br /> -- --.. ------ --
<br /> Registration Uate or Date
<br /> Vehicle Make Model Year 6pdy Type Vehicle Ideniification Number o(Acquisition if Newly
<br /> -------.._. .._._..-- ------ Purchased
<br /> — _... ----- ------...,..
<br /> �.O� ----- — .,. _..__
<br /> -------- -�`1r1`� c.,�ol� (Ff7X�K�51XH�(�'��b..7..`� - C��c' --
<br /> �rJr �'1 '�'.>� c�W�C�P� OZC"J C7 � U+" i 1 P�i�2 f'_,._.. .__... `-�'� �. 1�'1(��lr_.�_a�� _ �J-[)T-
<br /> �¢-� arn rc.C.K S�c,��� o f�-FP. Cab... .. .I_�z7 t�F i�3 z x l J"i�f a S_1_I �_d _i C7 . ......_
<br /> Nature of Use of Motor Veh.... _.---_. _...__ �... ..__-- —....... ... ....--- --._._ .
<br /> -— __. _.,,..____
<br /> icle. Are the motor vehicles u5ed
<br /> �Agricultural/Horticultural �Educational �Rcliyious �Charitable �Cemetery exclusively as indicated?
<br /> Give detailed description of use,including an explanation if multiple classifications exisC ; �� �
<br /> ' U+�It�. -�c���le� ��z cc� c� rr,ti:,�+rH�n�e �:�.pl�y��5 ��c,nc', c�:Ye ahc? bw�ld��� re�:;ra�
<br /> ��C����
<br /> If No,give percentage:,.,,__ %
<br /> �wGl JM1'1%:h�f'ti54�G.�. �C:� L'�SC'G� TCl TT'1✓�Sf'��'�" G'�l�vi�'`> [•h �;7ef� -Fr�PS�.{t �1nt �rcm .5r'7J.�
<br /> �ind�+C �7lterx��i� pl�,[�� �F ce�e , l7n��� �t5�c� ��•� m=�:rla-tn�:hce. �nc � y�rCt. uP �E�i � ����
<br /> S�p�I�r�S �'�� cr�er�;t.�cr�s�
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<br /> w�,t.��oun�-rv
<br /> 'f'REASUR�FtS�rF1GE
<br /> GRAN(715LANd,ht3:BR.ASKA
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<br /> Under penalties of law,I declare that I have examined this application and,to the best of my knowtedge and belief,it is correct and
<br /> complete.I also declare that 1 am duly authorized to sign lhis exemption application,and that the organization owning said property qoes not
<br /> discriminate in membership or employment based on race,color,vr national origin.
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<br /> here ----- �. _ ._� ..--. _ _---
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<br /> AuClio zed Si ature Title Date
<br /> _ -- ----------- -- --,... _. _. 1
<br /> FOR COUNTYTREASURER'S RECpMMENpA710N
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<br /> [J�APPRdVAL COMM[N7S: _��r�_/r.-�:�-5 / / 0,1�a. ,.,.•.,.—
<br /> ❑ b15Af'PROVAL
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<br /> /Signature of County Treasurer Date
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<br /> FOR COUN7Y BOARD OF E�UALIZATION lJSE pNI�Y
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<br /> ❑APPROVAL COMMENTS: —_.........
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<br /> [�DISAPPROVAL _...__.. _ _.. ..._ � ? � _",����, i. _
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<br /> Authorized Siynature Date
<br /> Nebras ..,..,.�..... . ._............... ......,._.. ...-----. ........ _._...,.....---. ..__....__. ......,...._ ._._
<br /> ka DeparUnent ot Revenue Authorized by NeU.Rev.6tat.§77-202(1)(c)(d),§60-3,785§60-3,189
<br /> 86-253-2006 Rev.S-2D09 SUper5ede5�J6-253•2006 Rev.11-2008
<br /> PLEASE MAKE A GOPY FOR YOUR RECbRDS
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