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� �.� �-�-- <br /> NebraskaDepartmentaf Application for Exemption FORM <br /> RE�NUE fram Motor Vehicl�Taxes by�ualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name 7ype of Ownership <br /> GOOD SAMARITAN 50CIETY-GI VILLAG� �Nonprvtit <br /> Street or pther Mailing Address Cvuniy Corporativn <br /> 4075 TIMBERLINE ST HALL <br /> []Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GF2AND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NQNPROFIT ORGANITA7ION <br /> Title Name,Address,City,Stale,Zip Code <br /> [" �(' <br /> � DESCRIPTIpN OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Regiseratitir:,ete pr <br /> MotorVehicle Make MDdelYear 8ody7ype Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> '� �' - � . <br /> _ � <br /> Exempt Uses ot Motor Vehicle: Are the motor vehicles used exclusively <br /> �AgriculturaVHorticultural ❑Educational �Religious �Charitable ❑Cemetery as indicated? <br /> Give detailed description ot use,including an explanation if multiple use classifications exist: �YES �NO <br /> � <br /> i '" � rt�������t� r � <br /> ��� --� ECEi��� <br /> NOV 1 8 2011 <br /> Under penalties vf law,I declar amined this application and that it is,to the best of my knowledge and belief true,complete,and correct.I <br /> also declare that I a horized to sign is exemption application,and that the organization owning the above-listed operty does not d�@�i�i�-1M1771' <br /> in membershi plo ent based on e,color,or national origin. '1'R�F,SURw.RS UFFICE <br /> GRANO I��.AtiD,NEBRASKA <br /> S I g 1"1 ����.._ //" / <br /> here Au rize ignature Title Dat <br /> � FOR COUNTYTREASURER RECOMMENDATION <br /> [�APPROVAL COMM�NTS� � /��S �J����� ,,,,,,_,,. <br /> [] �ISAPPROVAL <br /> -z� .. <br /> _�d /a �--�1-r..� <br /> �Signature bf County 7reasurer Date <br /> FOR COUN7Y BOARD OF E�UALItA710N U5E aNLY <br /> �PROVAL COMMENTS' _ <br /> ❑DISAPPROVAL <br /> � ����� <br /> Authorized Signatu Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,789 <br /> 9fi�253-20D6 Rev.8-2011 Supersedes 96-253-2006 Fav.5-2�G9 <br /> PLEASE RETAIN A CQPY FOR YOUR RECORDS. <br />