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ac� ��-.. <br /> �� Application for Exemption F�RM <br /> Nepreska Pepanmen[of <br /> REVENUE from Motor Vehicle Taxes by Glualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> NOR7HRIDGE ASSEMBLY OF GOD ❑Nonprotit <br /> Street or Other Mailing Address County Corpvration <br /> 3025 IN�EPENDENCE AV� HALL []Other(specify); <br /> Gity State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 6$803 NE <br /> IDENTIFY OFFICERS,DIR�CTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> � �rz wa�v v�'• 3 <br /> r� E � � i �s s�. A2 v�. c ,v ��03 <br /> '�SvREJ�- 57��ND 750 ?E�.Q iE 2 o b' e � 8/ <br /> /t SN l�E. f112.� 2Se s � �4�CE'GLa�vp NE. !F d3 <br /> DESCRIPTION O�7HE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br /> �p,gicsratlBq D^a�te or <br /> �ioptor Vehicie Mak� ModEl Year 8ody Type Vehicte ID Numqer Date of Acquiai ton, <br /> If Newly Purchased <br /> 1t=� F 35n o5� V' S53lLZ ��3�5''F ¢a7-4 ��1� <br /> � Sa v _� �S Dsff � � --0 4�—Zs�! <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Morticultural ❑Educational �Religious ❑Charita6le ❑Cemetery as indicated? <br /> Give detailed description oi use,including an explanation if multiple use classific�tions exist: �Y�S �NO <br /> �� (/��L.- / �"`''"�-- /� f'G/�- (J� Cf'i�f�,�`-~ �'Y� �L1/� �/1�{1`�" r <br /> .��;�. � ���: �'� t ��.. � g � � � E�ED <br /> I � SUKc�� C � <br /> �� � �� �� � � NOU 2 3 201] <br /> �,-Q.,afi�s �. � <br /> C.dac � <br /> llnder penalties of law,I declare that I have examined this application and thaT it is,to the best of my knowledge and belief, ue,complete,an y re��uNn <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed p perty does g d�F�C� <br /> in membership or employment based on race,color,or national origin. GRAf,J�J I�;_q�;;�,NEE3RASIGq <br /> sign , � /1.�.>~ �/r�l�// <br /> here Au orized Signature Tifle Date <br /> � mm�� � FOR COUNTYTREASURER RECDMMENDA7IDN <br /> [�APPROVAL COMMENTS: �� ���� <br /> []DISAPPROVAL -- -- <br /> � ��� _ _-- - -- --- - _i� ay-�/ <br /> ,Signature oF County Treasurer Date <br /> FOR COUNTY BOARD QF EpUALIZATION U5E ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> �`--'/� <br /> uthorized Signature Date <br /> Nebraske Departrnant of Revenue Authpnzed by Neb.Rav.Stat.§§77-202(1)(C)and(d),and 60-3,1p5,and 60•3,189 <br /> 96•253-2006 Rev.e•2o11 Supersedes 96-253•2006 Rev.5-2009 <br /> PLEASE RE7AIN A COPY FOR YOUR RECORDS. <br />