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�� 2011
<br /> 70BEFILEDWI7H Apps�cation for Exemption FORM
<br /> from MotorVehicleTaxes
<br /> YOUR COUN'rY by Qualifying Nnnprofit Organizations 457
<br /> TREASURER •Read instructions on reverse side _
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<br /> Appiicant's Name County Type of Ownership
<br /> MDSAIC xnr,�,_ ... �]No�,�ror�,
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<br /> Sireet or Other Mailing Address County Number Corporation
<br /> 2$46 OLD �"AIR RD 40 ........... .._ _.. .___ ❑other(speci�y):
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<br /> City State 7.ip Gode State Where Incorporatod
<br /> GRAAIll ISI.AND NE 68803 E ,_
<br /> Identi Oflicers Directors,or Partners
<br /> r,� _ .3 b'1-- � 1�,,"t.� .. ... ._ _...._
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<br /> Title Name Address,City,State,Zip Gode
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<br /> - ��-_�_�����c\-. � c . - _ _ . _ _. . _
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<br /> LIST SPECIFIG DESCRIPTION OF THE MOTQR VEHICLFS
<br /> � •Attach additional sheet if necessary
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<br /> - •• Registration Date or 17ate
<br /> Vehicle Make -�Model Year � Body 7ype � Vehi�le Identification Number oi AcquiSition if Novwly
<br /> Purchased
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<br /> Nature of Use of Motor Vehicle: Are the motor velyicles used
<br /> �Ac�ricultural/Horticultural ��ducational �Religious �Charitable �Cemetery
<br /> exclusively as indicated7
<br /> Give detailed description ot use,including an explanation if muttiple classifications exlst: �YES �NO
<br /> �•�v perp(.c�e�tage F`
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<br /> � Under penaities of law,I deciare that I have examined this application and,to the best of my knowledge a d belief,it is cofrc�utta�i�;tr?1'�
<br /> ,��:ice
<br /> complete.I also declare that I am duly authorized to sign this exemption application,and that the organization owni g said prop�fY�r3oes no(�`��;,_,,.;;;.� ;�k
<br /> discriminaYe in membership or em oyment based on race,color,or national origin. r'�"''`:.._...:,- •-•�-�^-"'""'"""��
<br /> siJn � � ���...� - � - 1 ( - I�1 � i c�
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<br /> here �tho z c�ignature Title Date
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<br /> FOR COUNTYTREASURER 5 RECOMMENDATION
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<br /> �APPROVAL COMMENTS: _r���._.,.._�/_��J�` ---. , - .�
<br /> ❑DISAPPROVAL _.__ _ __ _
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<br /> J ,� ,.�% __ _.�',� —/ ,
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<br /> ignature of County 7reasure� Date
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<br /> FOR COUN7Y BOARD O�E�UALIZATION USE ONLY
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<br /> ❑APPROVAL COMMENTS: . . -- --.._, ,, __.......T
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<br /> ❑DISAPPROVAL 1
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<br /> �Aut rized ignature Uate
<br /> Nebraska Departmen� ...� _,. .. .................. ._..,._ ._ .�. ..�--
<br /> t of Rovenue Authqrizpd by Neb.Rev.Sta�.§77-202(1)(c)(d),§60-3,1&5§60•3.189
<br /> 96-253-2006 Rev.5-2D09 Supersodes 96-253-2006 Rev.11-200fl
<br /> PLEASE MAKE A COPY FOR YOUR RECORDS
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