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�..t� �`�-�. <br /> ���� Application for Exemption FORM <br /> Na6raska Popartment of <br /> REVENUE from Motor Vehicle7axes by Dualifying Nonprofit Qrganizations 457 <br /> •7o be filed with ypur county treasurer, <br /> •Read instructians on reverse side. <br /> AppficanYs Name Type of Ownership <br /> �PWORTH VILLAGE INC �Nonprofit <br /> Street or Other Mailing Address County Gvrporation <br /> 2317 N KRUSE AVE HALL �pther(specify): <br /> ci}y State Zip Gode State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICER5,DIR�CTQRS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> 7' e Name,Address,City,State,Zip Gode <br /> � ° <br /> Ce ; ` p � <br /> � �` � <br /> �' e a G <br /> ` 7 <br /> DESCRIPTION OFTHE MbTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> MotorVehlcle Make ModelYear BodyType Vehicle ID Number Uate of Acquisition, <br /> if Newly Purch sed <br /> (� ,5 �. '3 <br /> e v y `�E�' <br /> /-% �.. 2� <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural(Horticultural [�ducational �ligious �,Charitable ❑Cemetery as indicated? <br /> / <br /> Give detailed description vf use,including an explanation if multiple use classific ions exist: ES �NO <br /> ��'Cs�v'��r,�C��f` ��1(�A ����i'� � C"c' '�.� � ��9�,''"`-�.. �—� l C' <br /> `�" � T�� � �e C�� 1 Y'-� S `� ��1 r °,9ive ����� <br /> l r �-v-�or�4- s � .5 <br /> c c���>--� � �-. � o�c-- �� �nv 3 a zo11 <br /> Under penalties of law,I declare that I have examined this application�nd that it is,to the best of my knowledge and beli f,true,complete�ho•�p�F,�� <br /> also declare that I am duly authorized to sign this exemption applicetion,and that the organization owning the above-liste property doe��n <br /> in membership or employment based on race,color,or national origin. GRAN f 5 E6RASKA <br /> � � <br /> s�9n _ � �es�� ���-}-- C�-0 �a t 1� <br /> h�ere Authorized Signature Title Date <br /> FOR C�UNTYTREASURER RECOMMENDATION <br /> „ 'APPROVAL COMMENTS:� ��S-_-��"aUoL <br /> ❑D15APPROVAL <br /> � ,,�.�E`"��41'�,�y� �d7 -ag�l'� <br /> �nature of County Treasurer Date <br /> FOR CQUNTY BOARD OF EQUALIZATION USE ONLY �� <br /> �PPRpVAL COMMENTS: <br /> ❑DISAPPRbVAL <br /> � <br /> �—�c� <br /> Authorized Signature Date <br /> Nebraska 4epar[ment of Revenue Autnorized by Ne6.Rev.StaL§§77-202(1)(c)end(d),and 60-3.185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-20�6 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />