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Application for Exemption FORM��
<br /> 70 B�FiLEDwi7H from MotorVehicleTaxes
<br /> YOUR COUNTY by Qualifying Nonprofit Organizations 457
<br /> 7REASURER •Read instructions vn reverse side
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<br /> Applicant's Name County Type af qwnership
<br /> '1EHAMA SHRTNE/C�.NTRAL NEBRASKA SIiR�.NE..CLUB
<br /> Rnr•�, __ Nanprofit
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<br /> 5treet or Other Mailing Address Counry Number Gorporation
<br /> 1903 W �O
<br /> RRF;Sx„ST YO,,B.QX �+y _.. _..,.._ ❑Other(specify):
<br /> Cjty m State Zip Gode State Where IncorpUrated
<br /> GRAND �SLAtdD NE 68802 NE _ °.--
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<br /> Identify Ofiicors,Direcinrs,or Parmers
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<br /> Tdle Name Address City,State,Zip Code
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<br /> LIST SPECI�IC DESCRIPTION OF�7HE MOTOR VEHICLES
<br /> f •Attach additivnal sheet if necessary
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<br /> - Model Year Bod T Vehicle Identrfication Number of Ac uisition if Ne r Date
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<br /> Vehicle Make y yp - ivn ate o
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<br /> Nature of 1Jse of Moivr Vehicle: Are the motor vehicles used
<br /> �Agricultural/Horticultural �Educ.ational �Religious /❑, Charitable �Cemetery exclusively as indicateq7
<br /> Givo detailed description of use,including an explanation if multiple classifications exist: �Y�S �NO
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<br /> ��J�'l�f�L.Yrw (.t r?� ��� .� �?�1!�I �(� ^�e:x!"y !��r i 4 e'� N��V����� %
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<br /> �� Under penaities of law,I declare that I have examined this application and,to the best of my knowl dge and belief,�,t��dY�kth�'R�f
<br /> compiete.I aiso declare that I am duly authorized to sign this exemption application,and that the organizati n awning sa7�9�r�iC�:iTbbsqi6P�G�
<br /> discriminate in membership or employment based on race,color,vr national origin. GRnNn ISLANn,NCBRAKSA
<br /> s i g n %f;,G�.t.�,.,1 �-�i,.,� %rt�s C'r� ��.��/`��" 5��f�fr G/�d �L �'��!�
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<br /> here Authorized Signature Title Date
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<br /> �� FpR COUN7Y7REA5URER'S RECOMMENDATION
<br /> [`�]yAPPROVAL ' COMMENTS: .,.. S� ��"���
<br /> ❑DISAPPROVAL ---..___ _._ _._.......T _........... .......—
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<br /> � �aL ,�'e ,��
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<br /> Signature of Gounty Treasurer Date
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<br /> FOR COUN7Y BOARD pF E�UALIZA710N USE ONLY
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<br /> ❑APPROVAL GQMMENTS: _...._.._ -- -................ .............. ...._�.--
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<br /> (�DISAPPROVAI. �l+ �
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<br /> / thorized Signature T Gate
<br /> Nebraska o�partment of Faevenue � � �� Authorized by Neb.Fiev.SIaL§77-`L02(1)(c)(d),§6D-3,165§60•3,1a9
<br /> 96-253•200E Rev.5-2009 Supersrdes 96-253-2006 Rev.11-200t3
<br /> PLEASE MAKE A COPY FOR YpUR RECORDS
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