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�O/>. <br /> �� Application for Exemption FQRM <br /> Ne6raska Dapartment of <br /> REVENUE rtrom Motor Vehicle Taxes by Dualifying Nonprofit Organizations 457 <br /> �7o be filed with your county treasurer. <br /> •Read instructians on reverse side. <br /> ApplicanYs Name 7ype of Ownership <br /> S7 PAULS LUTH�RAN GHURCH �Nonprofi� <br /> Street or Other Mailing Address County Corporativn <br /> 1515 5 HARRISON HALL []Other(specify): <br /> C�ty State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFIC�RS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT DRGANIZATION <br /> ��e Name,Address,City,State,Zip Code <br /> W � i S'15 �r? ./�Qinct� � <br /> � � <br /> pESCRIPTION OFTHE MOTOR VEHIGLES <br /> -Attach an additinnal sheet,if necessary. <br /> RegiStration Date or <br /> MotorYehicle Make ModelYear BodyType Vehicle ID Number �ate of Acquisitipn, <br /> if Newly Purchased <br /> �7 _ s T,az ka c i � � <br /> � <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exClusively <br /> �Agricullural/Horticultural ❑�ducational [�Religious �Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exisL [�YES �NO <br /> 1AJV uw`� `� , -- <br /> If No,give percentage of exempt use� <br /> ECEIVED <br /> D EC 1 5 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 be f,true,complete,and correct.I <br /> also declare that I am duly authorized fv�ign this exemp�ion application,and that the organization owning the above-list prvperty dces not discriminate <br /> in membership or employment based orv race,color,or national origin. HALL COUIJIY <br /> i T'REASUFtERS OFFlG'� <br /> - �' C3RAND ISI.AND,hEBRASKA <br /> f � n <br /> S I g 11 ', .��, ..�� t � ��� ��2.e.d�.�,�:t f�. l�.trn,c� I�-/,�'-// <br /> here �Authorized Signature ` Title �ate <br /> ti+' <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> [�APPROVAL COMMENTS: , �-��.�...���°���' - — <br /> ❑DISAPPROVAL �....__�. <br /> �' .,�.elr> >oz �—�-7 -�� <br /> Signature of County 7reasurer Date <br /> FOR COUNTY BOARD OF EQUAI.IZATION USE QNLY <br /> �PPRC7VAL COMMENTS: <br /> ❑DISAPPROVAI� <br /> i�/� <br /> fs orized Signature Date <br /> Nebre5ka Dapartment of Revenue Authorized 6y Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 80-3,1 B9 <br /> 96-253•2p06 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2D09 <br /> plEASE RETAIN A COPY FORYOUR RECORDS. <br />