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���� <br /> �� Application for Exemption Fo�M <br /> Nabraska Pepartmen[of <br /> REVENUE �rom Motor Vehicle Taxes by Clualifying Nonprofit Organizations 45„T <br /> •To be filed with your county treasurer, <br /> •Read instructions on reverse side. <br /> ApplicanYs Name Type of Ownership <br /> CENTRAL NEBRASKA HUMANE SOCIETY �Nonprotit <br /> Street or pther Mailing Address County Corporation <br /> 1312 SKYPAI�K RD HALL �Uther(specity): <br /> City State Zip Gode State Where InGOrporated <br /> GRAND 15LAND NE 68801 NE <br /> IDENTIFY OFFICERS,OIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> T le Name,Address,City,State,Zip Code <br /> ll e r cx-r� <br /> r r' u cc � a <br /> H r� -� a r 7 at So <br /> L+ . 1.c r'� e � Q 5 � Q r <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> +Attach an additional sheet,if necessary. <br /> ROnistratinn Uate Or <br /> MotorVehiele Make ModelYear BodyType Vehicle ID Number Date of Acquisition, <br /> Pf Newly Purchased <br /> •�D v7 D(] l 1I. ..��_..--- <br /> �V Y u. <br /> i I.t.l - d G <br /> Exempt Usos oi Motor Vehicle� Are the motor vehicles used exclusively <br /> ❑Agriculiural/Horticultural ❑Educationa) �Religious �harita6le ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classitications exist: N <br /> �tn i m c�.1 �Dr�~�r a L �tt.�..-�hU�'1�-� u S_e s�h�e s e �v i'' No,9ive p � � .._� <br /> P�eK t h 5 �DS+i S-�-Y c�� � j n 1 u r -e �l a.h'i n�7(:�--� 5 0.n � , <br /> J <br /> e n-�� c �e s � i�-�� o �re�,� cf L�h¢� �11 (�.h i ►�-�►a�.� Ni�Y � 7' 2a11; <br /> C�od�.5 a.�k �'��y �����n~��,� � s'�a�e �t"CI-�ecl,e�c�l ��°V e ls. ' <br /> T H,4LL <br /> Under penalties of law,I deClare that I have axamined this application and that it is,to the best of my knowledge and beli <br /> also declare that I am duly authnrizad to sign this exemption application,and that the organization owning the above-listed pro r y <br /> in membership or employment based on race,color,or national origin. <br /> Slgll - �f�e . �I�,L �1 / II <br /> here �uth zed Signature Title �� Date <br /> _ _..�._.�� <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> �APPRQVAL COMMENTS: ��/J• fVSS ���`�Qa--' � <br /> �pISAPPROVAL <br /> � <br /> /� ��-�/�__ <br /> Signature of Gounty Treasurer date <br /> FOR COUNTY BpARD OF E�UALIZATION 115E ONLY <br /> �APPRqVAL COMMENTS: � <br /> ❑DISAPPRQVAL <br /> /c��� <br /> Authorized Signature Date <br /> Nebraska Pepartment oF Revenue Authorized by Neb.Rev.SIaL§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-P53-2006 Rev.B-2011 Supersedes96•253-2008 Rev.5-2�09 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />