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�. �b�� <br /> '��'-�- Application for Exemption <br /> Ne6raska Dapartment vf ��RM <br /> �1GV'ENUE from Motor Vehicic Taxes by Qualifying Nonprofit Organizations <br /> ..,. . . •1�o be filed with your county treasurer, /��ry <br /> •Read instructions on reverse side. �f / <br /> Applicant's Name <br /> MID NEBRASKA INDIVIDUAL SERVIC�S INC TypeofOwnership <br /> Street or Other Mailing Address �Nonprofit <br /> County Corporation <br /> 2536 N CARLETON AVE hiALL <br /> Gity State Zi Code ❑Other(speciTy): <br /> P Stafe Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OPFICERS,DIRECTORS,OR PARTNERS pFTHE NONPROFIl"ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> � <br /> � v <br /> DESCRIPTION OF7HE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make Modet Year Registration�ate or <br /> BodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Exempt Uses of Motor Vehicle: <br /> Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious �Charitable �Cemetery as indicated? <br /> Give detailed description o}use,induding an explanaTion if multiple use classifications exist: �YES Q NO <br /> lo �ans(�ot-�-� Cje ���v�r�.n�a��.y a��SG.��e � ����� <br /> If No,giv e <br /> 1�R��V�1�U-�lS `�' �`��V l �e- �-�Cl.�l C.�S `�C?� % <br /> L°�M�]�p�flf��rl"� • ���, � � 20�� <br /> Hn��coura-rv <br /> Under penalties of law,I declare ihat I have examined this application and that it is,to the best oi my knowledge and beli f,true,co ��ne�� cAr�gt N�gRF�S <br /> also declare that I am duly authorized to sign this exemption appiication,and that the organization owning the above-liste <br /> in membership r employment based on ace,color,pr national origin. <br /> SIC�rt .. r- /�°�c�—/ <br /> ���"e nz n ia Titl� Date <br /> __^___�� _�______ FOR COUN7YTREASUR�R RECOMMENDATION <br /> [�APPROVAL COMMENTS� ��a�-�o�, � <br /> ❑DISAPPROVAL <br /> /�2 � /� <br /> Signature of ounty Treasurer Da e <br /> FOR COUNTY BOARD pF�QUALIZATION USE ONLY <br /> �PROVAL COMMEN7S: �,.. <br /> ❑D15APC'ROVAL <br /> /�—��---- <br /> uthorized Signat e Date <br /> Ne6reska�epartment of Revenue Authorized b Neb.Rev.Stat. <br /> 96-253-20p6 Rev.8-2091 Supersedes 96-253-2D06 Rev.5-2009 Y §§77-2D2(1)(c)and(d),and 60-3,185,end 60-3,18g <br /> PLEASE RE7AIN A COPY FOR YOUR R�CORDS, <br />