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°.� . �e�/� <br /> ��-� Application for Exemption Fo�M <br /> Ne6reska Dapartment of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprafit Organizations 457 <br /> •To be filed wkh ypur county treasurer. <br /> •Read instructions on reverse side. <br /> ApplicanYs Name Type of pwnership <br /> GOOpWILL INDUS7RIES OF GREATER NEBRASKA INC <br /> �Nonprofit <br /> Streat or bther Mailing Address County Corporation <br /> 1804 S EDDY ST PO BOX 1863 HALL <br /> City State Zip Code State Where Inwrporated ❑�ther(specify): <br /> GRAND 15LAND NE 68802 NE <br /> IDENTIFY OFFIC�RS,DIRECTORS,OR PARTN�RS bFTHE NONPROFIT ORGANIZATION <br /> Title Name.Address,Giry,State,Zip Code <br /> L7ESCFiIPTION OF THE MOTOR VEHICLES <br /> �Attach an additional sheet,if necessary. <br /> Registration Date or <br /> MoYor Vehlcle Mske Model Year BodyType Vehicle IU Number Date of Acquisition, <br /> if Newiy Furchasea <br /> L <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> []AgriculturaVHorticultural �Educational ❑Religious ❑Charitable ❑Gemetery as indicated? <br /> Give detailed de ription vf use,including an explanation if multiple use classificatinns exist: �YES �NO <br /> 1,.��d �a-r ��Lk,n..� u.p ar.d, ��.1C',n���rr� G1;��-�'.3 �-r 5 w�c�� <br /> b� G1�r.n..�s o�.c��V ��t�e.� ati� -�r��." A\� �sed �u ��- � , <br /> �A-w\�w.� P�_ �bt\CL�[�4S � '�w�PGy-f'T O[� ��a�l'�n�5 ----��CEIVED <br /> �' a�si��� 1� ���� , <br /> DE'C 2 2011 <br /> Under penalties of law,I declare that I have examined this applicativn and that it is,ro the best of my knowledge and beli ,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-liste property do.sDo��W7Y <br /> in membership or employment based on race,color,or national origin. TR�SlJRERS QFFIC� <br /> GRAND ISLANO,NEBRA9KA <br /> sign � � <br /> r �a- d(- � � <br /> here Authorize Signature Title pate <br /> � �OR GPU1dTYTRcASURER REG�iNEV'iEP1DA.TlOt•i <br /> _ —_. _..._.—.,_ <br /> �PPROVAL COMMENTS: //aB�"� <br /> ❑DISAPPROVAL <br /> � / a� <br /> Signature of County 7reasurer pa e <br /> FpR COUNTY BOARD OF EpUALIZATION USE ONLY ' <br /> ....._.. �.__ <br /> �1'I'ROVAL CDMMENTS: <br /> ❑�ISAPPROVAI. <br /> ��/��-- <br /> uthorized Signat Date <br /> Nebraska Depar[ment of Revenue � Authorized by Nen.Rav.Siat.§§77-2D2(i)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 5upersedes 96•253-2006 Rev.5-20p9 <br /> PLEAS�RETAIN q COPY FOR YOUR RECORDS. <br />