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��Ir� <br /> ��-� Application for Exemption FORM <br /> Nedraska�epercment af <br /> REVENUE from Motor V�hicleTaxes by Glualifying Nonprofit Organizatians 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> ApplicanYs Name Type of Ownership <br /> HARVE57 TIME BAPTIST CHUI�CH �Nonprotit <br /> Street or Other Mailing Address County Corporation <br /> 1125 N BEAL ST HAL.L [�otner(speciry): <br /> City State Zip Gode State Where Incorporated <br /> GRAND ISLAND NE 68$01 NE <br /> ID�NTIFY OFFICERS,DIHECTORS,~4R PARTNERS OF THE NONPROFIT ORGANIZATION <br /> 7itle Name,Address,Gity,State,Zip Gode <br /> � A`-�iT]r'� i'IGr`L � ��1)��' � 2 'C 7 " �rr... �� .�[c� Jl ��2� <br /> � V"C4a.acS�-� � � �'P� �rl.� CM�W'P�S _ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Rey�stration Ca:x or <br /> Motor Vehicle Make Model Year Bndy Type Vehicle I�Number Date of Acquisitipn, <br /> i}Newly Purohased <br /> �o�7G Lz 1 1' 1 �-� C-�I� S � �v'i K4s�s /� � <br /> Exempt Uses af Motor Vehicle: Are the motor vehicles used exclusively <br /> �Agricultural/Horticultural �Educational �]Religious ❑Charitable ❑Cemetery as indicatad? <br /> �\ <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES �NO <br /> �� • /�-/� �� � ��Q� �'C ��G� ��1'L����� 7r- If No,pl������use: <br /> �`" '" ' {�✓ C�/�) �"�� V � <br /> p�C � 9 2011 <br /> Under penalties of law,I declare that I have examined this application and that it is,to Ihe best of my knowledge an belief,True,s�{� ���14�r�FtIG� <br /> also daclare that I am dul authorized to sign this exemption application,and that the organization owning the above sted proqy�IFlQ1�t�CtU��f+SKP` <br /> in membershi p oymen d on race,color,or national origin. <br /> S�gn ` �_ �r � d ��C <br /> here Authorized Signature Title � <br /> FQR COUN7Y7R�ASURER R�COMMEN�ATION <br /> �APPROVAL COMMENTS� • �� �a��, <br /> ❑DISAPPROVAL <br /> �'�.�� /.2�-y_�/ <br /> Signature of County Treasurer Date <br /> FOR COUN7Y BOARD OF�QUALIZATIpN USE ONLY <br /> �PPFiOVAL COMMENTS: <br /> ❑DISAPPRQVAL <br /> ���� <br /> Authoriaed Signature Date <br /> Nepraska�epartment of Revenue Authorized by Neb.Rev.StaL§§77-202(�)(c)and(d),and 60-3,185,and 60•3.189 <br /> 96-253-20D6 Rev.B-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE R�TAIN A COPY FOR YpUR RECORDS. <br />