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<br /> Tp BE FILEDWITH Application for Exemption �.l�,�!�" �^� �ORM
<br /> YOUR COLJNTY from Motor Vehicle Taxes ,, ,r(�
<br /> by Qualifying Npnprofit Organizations � ,457
<br /> TREASURER •Read instructions on reverse side _
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<br /> Applicant's Name County Type of pwnersPiip
<br /> Nebraska State � �' + t� ��d-Y"� Hall 0 Nonprofit
<br /> ., - ---.....-- -- _
<br /> Street or Other Mailing Address County Number Gorporation
<br /> �� BOX �387 _ ,. _�'"c� �$�_.... .__ �Other(specify):
<br /> _,... _ _.
<br /> City State 7ip Code State Where Incorporated
<br /> Grand Island NE 6$$02 Nebraska ----- - -
<br /> . . ---._ _.._..,.._ _.. .....
<br /> Identify Otficers �irectors or Partners
<br /> I', .. -- -... __. -- - _. — ,
<br /> itle Name,Address,City State Zip Code
<br /> See Attached
<br /> _ _. — ,.__ _ _.._ �
<br /> � LIST SPECIFIC DESCRIPTION t�F THE MOTOR VEHICLES
<br /> Attach additional sheet if necessary
<br /> _.... _. .-- --.. .T.._...-- -�.... __.. - --. _._.--- --..._. ...-
<br /> Registration Date or Date
<br /> Vehicle Make Model Year Body Type Vehicle Identification Nurnber of Acquisition if Newly
<br /> -,,, - --... ...._
<br /> Purchased
<br /> Gh�:vrolet Impala 2003 Sedan 2G1 WF55E339381047
<br /> . __ ... __._.. _ _._.. _ __....
<br /> Chevrplet lmpala 2�04 Sedan 2G1 WF52�849247415
<br /> _.. _.. ------ _. —.
<br /> Cy1�-V1"CL�'� _ s�GC7�___ �✓'��-�1�i�G,GtU GC�f<_►4753z�'7�:'�y_
<br /> - -... _
<br /> ��Y��`�_t:��• 1�1"i'7 �-k-�4�L-t"rL.r . y'I�iD(3Ai(�3.�1-V le�e?3?"/3
<br /> -- _ _.._... -- - ..
<br /> Nature of Use of Mptor Vehicle: Are the motor vehieles used
<br /> �Agriculiural/Horticultura� �Educational �Reliyious �Charitable �Cemetery
<br /> exclusively as indicated?
<br /> (3ive de[ailed desr,ription ot use,including an explanation i1 multiple classifications exist: �Y�5 �NO
<br /> These company vehides are used by the Nebraska State 'Fw3+�,�^whd and staff for
<br /> .
<br /> company use only. T_ _
<br /> . � ��r�� �--
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<br /> _ co _.... _ _.
<br /> Under penalties of law,I deelare that I have examined this application and,to the best of my kn ledge and belief it isrcorrect and
<br /> mplele,I also declare that I am duly authorized to sign this exemptian application,and that the organiz tion owninq� b�p,er���de�"
<br /> discriminate in memhership or employment based on race,color,or national origin. -7R-.q�t-;Y;f-f<,:<�r_�6��r
<br /> C`zRA"1D ISt./�.P;U.t..�E �
<br /> !,'_� , � _..,_..
<br /> S'g� .•'�.,�.:'� J•� �,��I/�.� Administrative Assistant o4108lZ011
<br /> , �
<br /> '� � -.,._..' _--....._..,.,..._...._
<br /> • .... __—.._...
<br /> E . .mGL
<br /> .�
<br /> h�Ce .
<br /> �fA�, orixed Signature TiUe �ate
<br /> ;/ _, -- _ _ ... _ -- -. -- -......,.�
<br /> FDR COUNTY7REASURER'S RECOMM�NDATION
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<br /> � ..._.._. -- _.. .. _.-- -... _ _,....
<br /> �J APPF�OVAL COMMENT�.. _�..�-L� ��y�����—.._.., .....
<br /> �"�--
<br /> �]DISAPPFIOVAL -.. —.. .. —
<br /> ,.� � �/ qr
<br /> ` • �1�L^��.� _.._._... _. `7` c�G ��
<br /> I Signature oi County Treasurer ate
<br /> _., -. -. _ ..,., _....-�
<br /> FOR C4UNTY BOARD OF EQl1ALIZATION USE�NLY
<br /> �AI'PROVAL CQMMENTS: --._ , __.._...., ..--- -.. ..— -....._
<br /> �-�
<br /> I.]DISAPPROVAL _.,_ _.�...... _T ...
<br /> � �
<br /> - -. - ---- .
<br /> ..�~'/(� -f1
<br /> horized ignature Date
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<br /> Nebraska oepartmern of Revenue Authonzetl by Neb.Fiev.Stat.§77-202(1)(C)(d),§60-3.185§603.189
<br /> 96•253-2006 Rev.5•2oa9 Supers'zdes 96-253-2o0G Rev.11•2oDa
<br /> PLEASE MAK�A COPY FOR YOUR RECORDS
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