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<br /> �--- Appiication for Exemption �o�M
<br /> Nebraska DeparCrngnt of
<br /> ���p��� firom MotorVehicle7axes by Ctualifying Ndnprafit Organizatians 457
<br /> I1E •Tp be filed with your county treasurer.
<br /> - •Read instructions on reverse side.
<br /> . ..__ ___..�._..__.—.�.....,...__
<br /> ApplicanYs Name / Type of Ownership
<br /> l✓e.�►-t�G�H" �^u Y'KErx�r-t �;�G SG�O�..._.... �_.._.___ �Nonprofit
<br /> Street or Other Mailing Address -6� County Corporation
<br /> 3 `�00 L.,� �u,r��r � �ix// ❑ocner�5�o�ry�:
<br /> Ciry ��State Zip Gode w Sfate Where Incorporated
<br /> �'� rav� ����� ��- 6��r03 .l��
<br /> m� IDENTIFY OFFICERS,DIREGTQFtS,OR PARTNERS DFTHE NONPRQFIT pRGANIZATIpN
<br /> �_ . _._. �.._ ...._....._._....,_..�---,..__..__
<br /> 7itle Name,Address,City,State,Zip Code
<br /> rt?,' _��w�.�'�; uu�� ��3 A�-,zof l���k.°���--��..._���'3�_�.._.___ �-__
<br /> ....._ S�c r�f� �,r� /����....��_..�..�/..f� / .// �i��rf_3
<br /> __.� )__TYl�°d'.ruv�u;?rruU,�_ � 6 f'G�v.✓l c�5.� /��� Q�i/a.'s+c S�.__._�C�"�..����tt����__...�
<br /> ViG —.,.�� �u �ti._. �������.,.v� . G�'.�..�-�_.�..___�_._.�._......�_�..._.
<br /> ._... "_.."" DESCRIPTION OFTHE MOTOR VEHICLES -_......,_.___._ _�.__............
<br /> •Attach an additiona)sheet,if necessary,
<br /> __ —_........ ...._.�._..._.._....,.__.__...�.,._.._.._...
<br /> f�egistration f7ate or
<br /> MotorVehicle Make ModelYear BodyType Vehicle ID Number f]ate of Acquisitipn,
<br /> _..._��.... __....... �.. ---._..._____...�...�_ .._._..._.�....._...._..
<br /> if Newly Purchased
<br /> ...k��r Hn�i0c.a � ��99 �3u _.__...._....�._... �..H..y�..Ts� � O �O/
<br /> ._.._�.�.....__�......_.�
<br /> Exempt Uses af Motor Vehicle: �� � �re the mvtor vehicles used exclusively
<br /> ❑Agricultural/Worticultural �Educational �Religious i,_,�Charitable �Cemetery �s indicated?
<br /> Give detailed description af use,including an explanation if multiple use classifications exist: �YES �NO
<br /> S��tio n� b�-� �c� `c7� L.t..S�� �-�C`.�K 1� -�t�V ��c c�rS�7G`r"�� �`�
<br /> ,��`����S }� ��,K �• ��p y ` 5�4�t�, ��.�,,.,�w� -Q�� If No,give percentage ot exempt use:
<br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and balief,true,complete,and correct.I����
<br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate
<br /> in membership or employment based on race,color,or national origin.
<br /> $1 g 1� -��a���i��"`"�.-- --- �je.�.'r. /'r.iec.�f.<„�,__ ��-�OIL
<br /> here Authorized Signature Title � �� Date
<br /> � FAR GQUNTYTREASURER RECOMMENDATION
<br /> �PPRQVAL CbMMENTS: �V�ti �J�� ���� ���
<br /> ❑DISAPPROVAL —���.�._..
<br /> �� -�� � — ��
<br /> _/ :,J''� �'�
<br /> �Signature pt County Treasurer 'T� � Date
<br /> � FOR COUNTY BOARD OF EQUALI�ATI�N USE pNLY
<br /> �APPFiOVAL CpMMENT5: _..._�._.�..,.—,
<br /> [�DISAPPROVAL ._ —�.-•-..------.--..- ..--..�...
<br /> ,/� �oii
<br /> onzed Signature Qate
<br /> Nebraska Dgpartment ol Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,195,and 6o-3,189
<br /> 86-253-2006 Rev.B-2011 Supersades 96-253-2�06 Rev.5-20a9 �
<br /> PIEASE aETA1N A COPY FORYOUR RECORD5.
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