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�ut�- <br /> w���� Application for Exemption FORM <br /> Ne6reska DepaRmBnt of <br /> REVENUE fram Motor VehicleTaxes by oualifying Nonprofit Qrganizations 457 <br /> •To 6e filed with your county treasurer, <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> H�ARTLAND LUTHERAN HIGH SCHDOL �f Nonprofit <br /> Street or Other Msiling Address County Corporation <br /> 3900 W HUSK�R HWY HALL <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRANp ISLAND NE 688D3 NE <br /> IDENTIFY OFFICERS,DIREC70RS,OR PARTNERS OF7HE NONPROFIT ORGANI�A71�N <br /> 7itle Name,Address,City,State,Zip Code <br /> i i / / Y� � <br /> (/0 'r �✓ . ' � <br /> S - u olt�rtSc�-� . /90 � <br /> i air� S s � � <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Ragis:ration Ds o cr <br /> Motor Vehicle Make Model Year BndyType VehiCle ID Number Pate af Acquisition, <br /> if Newly Purchased <br /> ->fi l G- 9uJ�1 X� �i Z !� <br /> ZU� � ca i F` �i�/L'� HB 1� <br /> / / �j[� /G- l9E'/�=sG v�I � <br /> �' �Q " ��k/� Z 3� <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural �ducational [�"F�aligious ❑Charitabte ❑Cemetery �s indicated? <br /> Give detailed description ot use,including an explanation if multiple use classifications exist: ES �NO <br /> ��?r.�.�- �c.lt��I - �an�e.a 9��2 <br /> .S �� �s� �o .� � �un�� � � <br /> l wans ,-7� � � `� � / <br /> � , <br /> �C.7ar�v� �r-C S 4'� �'�• NQY 2 3 2011 <br /> (� a�- �5- aa <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and belie,true,complete, rrEr,�`LN T.Y <br /> also declare that I am duly authorized to sign lhis exemption application,and that the organization owning the above-lisled roperty doe S'`������ <br /> ER.�P�FICE <br /> in membership or employment based on race,colvr,or national origin. [3FWND ISLArJC),NE8�2ASKA <br /> i <br /> sign ����,� �i�Z�-ll <br /> here Aut�Signature Title Date <br /> FOR COUNTY TREA5URER RECOMM�NDATIQN <br /> �PROVAL COMMENTS� �� � �a'DO� <br /> ❑PISAPPROVAL . <br /> . ,�� `7���� /� ��-�!/ <br /> Signature of County Treasurer Date <br /> FOR COUNTY BOARD 4�EDUALIZATION U5�QNLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPRQVAL <br /> ` � ���r� <br /> uthorize Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77ao2(1)(c)end(d),and 60-3,785,and so-3,189 <br /> 96-253-2006 Rev.B-2p11 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE R�TAIN A COPY FORYOUR RECORPS. <br />