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�,.,,,�.�"° <br /> TQ BE FILEDWITH Application for Exemption FORM <br /> YOUR couN'rY from Motor Vehide Taxes <br /> TREASURER . by Qualifying NDnprafit Organizations 457 <br /> •Read instructions on reverse side <br /> ApplicanYs Name , County Type oF Ownership <br /> 1 n ` <br /> � ,,�1 � ...�� � �t � ` �Nonprofit <br /> Street or Other Mailing Address County Number Corporation <br /> `O� � ❑Ofher(sPecily)= <br /> Ci State �ip Code State Where Incorporated <br /> � a N�. ��. <br /> Identify Officers,Directors,or Partners <br /> Title idame,Address,City,State,7rp Code <br /> LIST SPECIFIC DESCRIPTION OF TME MOTOR VEHICLES <br /> •Attach additional sheet if necessary <br /> Registration Date or Date <br /> Vehicle Make Model Year Body Type Vehicle Identification Number of Acquisi6on'rf Newly <br /> Purchased <br /> ca� Do Lo �7 LT tJ 17. i � <br /> NaYUre ot Use of Motor Vehicie: Are the mowr rehicles used <br /> ❑AgriculturaVHorticultural �Educational ❑Religious ❑Charitable ❑Cemetery ezclusively as indicated7 <br /> Give detailed descriptian vf use,including an ezplanation if multiple classifications exist: �]YES �NO <br /> � � <br /> �. � <br /> -� ` � ` �`' � � D EC 1 9 2011 <br /> HAI.I.GC�UNTY <br /> Under penaRies of law,I declare that I have examined this application and,to the pest of my led �`�t�' ,,,p, <br /> complete.I also declare that 1 am duty suthorized to sign this exemption application,and that the o - - - - <br /> discriminate in membership or emplayment based on race,cobr,or national origin. _._. :�tASKA <br /> sign � ' �. ��,-�q-- 11 <br /> here �t aed Signature rt� o�te <br /> FOR COWNTYTRFJ�SURER'S RECQMMENDATI�N <br /> �APPROVAL COMMENTS: � �'� '7 �� �� <br /> ❑DISAPPROVAL <br /> � � <br /> �� a / <br /> Signature ot County Treasurer aate <br /> FOR COUNTY BOARLI pF EQUALIZATION USE ONLY <br /> �J APPFiOVAL CbMMENTS: <br /> f� <br /> ❑DISAPPROVAL <br /> l:.�-/�.- <br /> Authorized Signature Date <br /> Nebraska Department of Revenue Authonzed by Ne4.Rev.S[at.§77-202(1)(c)(d),§60-3,185§GO-3,189 <br /> 96-253-2006 Rev.5-20D9 Supersedes 96-253-2006 Rev.71-2008 <br /> PLEASE MAKE A COPY FDR YOUR RECORDS <br />