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.�. a� ��-- <br /> ,�e��� Applicativn for Exemption �oRM <br /> Nebraska DeparCment of <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit�rganizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name '�ype of pwnership <br /> Mosaic <br /> ___ �Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2846 OLD FAIR RD HALL <br /> ____ ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 688Q3 NE <br /> IDENTIFY O�FICERS,DIRECTORS,QR PAR7N�R5 OFTHE NONPROFIT�RGANIZATIpN <br /> 7itle Name,Address,Gity,State,Zip Code (� �f/ � — w� O <br /> L <br /> � �� DESCRIPTION pFTW�MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle Iq Number Dafe of Acquisition, <br /> It Newly Purchased <br /> Exempt Uses of Motar Vehicle: Are the mptor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational �Religious �Charitable �Cemefery �s indicated7 <br /> Give detailed description ot use,including an explanation if multiple use dassific�ations exist: �YES �NO <br /> ��� <br /> l o �Y'u�ls�or� d�saa� �h�r�r� �luc�ls �f , ,� p ; � D <br /> NQV 1 fi 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 belief,t ue,complete,an�q�@c�bUNTY <br /> also declare that I am duly authorized to sign this exemption applicatinn,and that the org2nization owning the above-listed pr perty does n�S QFFIC& <br /> in membership or employment based on race,color,or national origin. ����7�SLANO,MEBRASKA <br /> sign . ��'� �:� _ $�Li�ess I�1u�Ic�U-�' I � l i� / ! <br /> - here ���zed Signature Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> �PPROVAL COMMENTS' ��d�` <br /> ❑DISAPPROVAL --�,.— <br /> � <br /> ,�,� /�a 9-�/ <br /> �S'ignature of County Treasurer pate <br /> FOR COUNTY BOARD OF EQUA4IZATION IJSE ONLY <br /> �PPROVAL COMMENTS: <br /> ❑bISAPPROVAL ----- <br /> ��'�-� <br /> Authorized ignatu Date <br /> Nebraska Departmeni of Revenue Aulhorizad by Neb.Aev.Stat.§§77ao2(1)(c)and(d),and 60-3,185,end 60-3,189 <br /> 96•253-2006 Rev.8-2011 5upersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A CQPY FOR YOUR RECORDS. <br />