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���� <br /> ,o�� Appiication for Exemption FORM <br /> Ne6raska Depertment of <br /> REVENUE from Motor VehideTaxes by Glualifying Nonprofit Organizations 457 <br /> •Ta 6e filed with yaur county treasurer. <br /> •aead instructions on reverse side. <br /> ApplicanYs Name Type of Ownership <br /> HOPE HARBOR INC �Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> Fi10 W DIVISION ST PO BOX 1544 HALL �Other(speciiy): <br /> City State Zip Code State Where Inwrporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTN�RS pFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Z.�.�� ...JQ. � �Z..l.�}� � .�1 ��� �'�- 1: Vu. � �1�15 i ii'1 .�-.d"t i.� a�Cl�t /li��'� �^ <br /> �1�2 S��',%�a 1 j�,� �:+�•na t , i�1 :, -CC� nC�� %J _ � <br /> V u: ��`2 s,cli-� � L� �r�m � t�`IC W �-� �., C. f )cin _ . ��, <br /> �(YY '"�'C.vl� .�/i Jr)1 C� �•Qci /� _ <br /> D�SCRIPTIPN OF7HE MOTOR VEHICLES <br /> •,4ttach�n ar)di±iona!shPe?,jf no,r.ecca�y. <br /> Registration Uate Or <br /> MatorVehicle Make ModelYear Body7ype Vehicle ID Number Pate of Acquisition, <br /> if Newly Purchased <br /> � � b �-�� v D� � , <br /> Exempt Uses of Motar Vehicle: Are the motor vehicles used exclusively <br /> [�Agricultural/Horticultural ❑Educationat ❑Rsligious Q Charitable ❑Cemetery <br /> as indicated7 <br /> Give detalled description of use,including an explanation if multiple use classifications exist: f �YES �NO <br /> � k o�' I�uv�a.Le� �es ic�?:�S �r� n���aP cie�naa�ti'�-��,��c'� <br /> ���5� If No,give percentage of exempt use: <br /> -�i�,� ���s���.��.�, ����,�ti�, �,,,,-.�� . ECEIV�� <br /> pEC l 3 2011 <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,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed roperty does not discriminate <br /> in membership or employment 6ased on race,color,or nationat origin. �ALL.COUNIY <br /> TREASUFt�R$t7FF10E <br /> , GRP,NI]IS�AND,N�BRASKA <br /> sign ;J� __ ��.�.�.�,�1r� D;'Y�z c�i�..� _ I ��, �a <br /> ���"� Auth rized Signature ��1e <br /> FpR COUNTYTREASIJRER RECpMMENDATION <br /> [�APPROVAL COMMENTS: �d ra"�°�` <br /> ❑DISAPPROVAL <br /> /�3 --�-7—�/ <br /> Slgnature of County reasurer Date <br /> FOR COUNTY BOARD AF EpUALIZATION USE ONLY <br /> APPR�VAL COMMENTS: <br /> �DISAPPROVAL <br /> /��� -- <br /> Authorized Signatur Date <br /> Nebraska Departmant vf Revenue Authorized by Neb.Rev.S�ac§§77•2o2(1)(c)and(d),and 6o-3,185,and 603,789 <br /> 96-253-2D�6 Rev.8-2011 Supersedes 96-253•2006 Rev.5-2p09 <br /> PLEASE R�TAIN A COPY FORYOUR RECPRDS. <br />