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���' <br /> ��- Application for Exemption �o�M <br /> Ne6raska papartment of <br /> REVENUE from Motor Vehicle Taxes by Glualifying Nonprofit Organizativns 457 <br /> •To be filed with your county treasurer. <br /> "�' ' •Read instructions on reverse side. <br /> ApplicanYS Name Type of Ownership <br /> SENIOR CITIZ�NS WDUSTRIES INC (`yJ Nonp�otit <br /> Street or Other Mailing Address County Corporation <br /> 304 E 3RD ST HALL ❑otne��SPe�;ry>: <br /> Ciry State Zip Code State Where Inwrporated <br /> GRAND ISLANb NE 68801 NE <br /> IDENTIFY OFFICERS,DIREGTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> • DESCRIPTION OFTHE MpTORVEHICLES <br /> •Attach an additional sheet,if necessary, <br /> Registration Gate or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number Date vf Acquisition, <br /> _... If Newly Purchased <br /> Z � <br /> Exempt Uses of Motor Vehicle� ' Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious �Charitable ❑Gemetery as indiCated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: �YES �Np <br /> � ~�5 U�1�fe.C"1.� ��'C' �(1,E�a�►S o�c7. ta.9�e�5 ir Na,e��e� <br /> r-r,v r �� ���� <br /> �;.,;-�-,�,n -}-�.1��,., , <br /> DEC 1 � 2011 <br /> lJnder penalties of law,I declare that I have examined this applic2tion and that it is,ro the best of my knowledge and b ef,true,corr� <br /> also declare that I am duly authorized to sign this exemption application,and that the nrganization owning the above-list propert�� t FFlCE <br /> in membership or employment based on race,color,or national origin. �RASKA <br /> sign � <br /> here uthorized Signature ul Date/�����~� I <br /> FpR COUNTY 7REASURER RECOMMENDATION <br /> �APPROVAL COMMENI'S: � � ` �r�+ <br /> ❑DISAPPROVAL <br /> � � /� �J—! / <br /> Signature of County Treasurer Date <br /> ��� FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> �APPROVAL COMM�NTS: <br /> ❑DISAPPROVAL <br /> /�/� <br /> uthorized Signat Date <br /> Nebraska qepartmanl of Revenue Authorized by Ne6.Rev.5lat.§§77•202(7)(c)end(d),and 60•3,185,and 60-3,189 <br /> 96-253-2006 Rev.8•2011 Supersedes 96-253-2006 Rev.5•2009 <br /> PLEASE RE7AIN A COPY FOR YOUR RECORDS. <br />