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a.�l �-. <br /> ���- Application for Exemption �o�M <br /> Ne6raska Oepartment of <br /> REVENUE from Motor Vehicle Taxes by�ualifying Nonprofit Qrganizations 457 <br /> •7o be filed with your county treasurer. <br /> •Read instructions pn reverse side. <br /> Applicant's Name Type of Ownership <br /> SERVANTS OF MARY SR RITA KOLBET � �Nonprotit <br /> Street or Other Mailing Address County Corporation <br /> 821 ORLEANS DR HALL �p�her(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 6$803 NE <br /> IDENTIFY OFFNC�RS,DIRECTORS,OR PARTNERS OFTHE NONPRO�IT ORGANIZATIpN <br /> 7itle � h�' I' ;� Name,Address,City,State,Zip Code <br /> a!� C�i2, P l�- �C�� 1 i C�l- cti �� C� �/ <br /> p �f l- �'M �i �/ <br /> DESCRIpTION OFTHE MpTbR VEHICLES <br /> •Attach en additional sheet,if necessary. <br /> Registration I�ate or <br /> Motor Vehicle Make �odel Year Body Type VehiGe I�Number Pate of racquisitinn, <br /> If Newly Purchased <br /> , "q� ��� G _.�- ) ���h 7`' X �'" L w i / � ,G <br /> Exempt Uses of Motor Vehicle� Are the motor vehicles used exclusively <br /> �AgricuHuraVHorticultural ❑Educational �Religious ❑Charitable �Cemetery as indicated? <br /> T� <br /> Give detailed description of use,including an explanation if multiple use classifications exist: �YES �NO <br /> ,,( / <br /> ��. �r'�. ��;.[. S �r r i� S rLy �' *t c� �� �� / � � �C� ��, �/� � j `� IfNo, se: <br /> �, ��� <br /> Nov � � zo1� <br /> lJnder penalties of law,I declare that I have examined this application and that it is,to ihe best of my knowledge an belief,true,com t�kr��►Af3ifil <br /> also declare that I am duly authorized to sign this exemption application,and fhat the organization owning the above isted prop r S�t��k�i�'ICE <br /> in membership or emplvyment based on race,color,or national origin. � Np��'..AND,NEBRASKA <br /> sign � � . � ,>�,�, ���- ��.c�, -!.� �'% � --- � 1 , / y %/ <br /> here Auihorized Signature Title d �ate <br /> FOR COUNTYTR�ASURER R�COMMENDATIpN � <br /> �APPRQVAL CdMMENTS: �� /L�� ��/ �°�°Z _ — <br /> ❑DISAPPROVAL , , --- <br /> r ,�����-��,�.�� ��--�-l-1 l <br /> �Signature o�Cpunty Treasurer Date <br /> FOR COUNTY BQARD OF EOUALIZATION USE ONLY <br /> �APPFiOVAL COMMEN7S: <br /> r . , <br /> ❑DISAPPROVAL <br /> I--� �-- <br /> uthorize ignatu Date <br /> Nebraska Department of Revenue Authonzed by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60.3,185,and 6P-3,189 <br /> 96-253-2006 Rev.8-2D11 Supersades 96•253-2006 Rev.5-2009 <br /> PLEASE RETAIN A CQPY FORYQUR RECORDS. <br />