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12!�7/2011 11:54 FAX 308 385 5061 Hall CO D�V [�ODD2/DD02 <br /> , o�O/� . <br /> �►��- ApplicatiQn for Exemption FoRM <br /> Na6reska peparrrnent af <br /> ��NUE frvm Mator Vehicle 7axes by Duatitying Nonprofit Organiz�atinns 45„T <br /> •7o be msd wRh yvur caumy treasurer. <br /> •Read tnstructiona on rowra.aide. <br /> Applicant's Name 7YPe'oT 4wnership <br /> TEHAMA SMRlNE/CEN�RAL NEBRASKA SHRINE CW$ �di� �Nonprotit <br /> 8lreet ar Othsr Mailing Address County Corporation <br /> 5575 S ENGI.EMAN RD HAi.I. <br /> ❑other(speciry): <br /> ��y Stata T-ip Code Scata where Incorporated <br /> GRAND 151AND N� 68803 N� <br /> IDENTIFY DFFIC�RS,[lIRECTORS,OR PARTNERS OF 7'HE NpNPROFIT ORGANIZATIpN <br /> Titie Nart�,Address,City.Slete,Zp Code <br /> LARRY HOBBS-PRES 1903 W FORR�ST ST GR{1ND 15LAN0 NE 68803 <br /> DON VDGEL-S�G 9811 S'7Ac3ECAUCH RD GRAND 15LAND NE BS$01 <br /> WILLIAM CARSON-TREAS 5575 5 ENGLEMAN R�GI�AlVD ISLAND N�S88U3 <br /> DESCRIPTtON QFTHE MOTOR VEH�CL�S <br /> •Attach an additional gheet,N necessary. <br /> Ragjetrstlon Daus or <br /> MotvrVehide Mak� M�ode�Yaar Botly7ype Venlcie Ip Number �ate at Acquisition, <br /> if New Purchased <br /> DODGE RF,M PICKUF 2002 15�0 QUAD CAB 1 D7HA18NY255i1594 <br /> � _ <br /> �csmpt Uses of Moror Vehicle: Are the mvla vehictes used exdusi,rely <br /> [�Agricullural/Horticuftural ❑�du�ational ❑Fieligious �CharitsWe ❑Cemetery as indicated7 <br /> Give deiailed descripdon af use,includinp 8n explanation li multiple use classificstiona exist: �YES �NO <br /> (�S�J �, '1��/ �;,r /�w.°v c% f� �,�✓'L %74 y f� - N o;give per���F7'.'�� .. <br /> .. 1 , . <br /> �/1�"�n� 17���y� �v� �.� ..- ��� �[��`�rrs 1� t�=�f �� <br /> ��-h.����� � � ��, r�� ff��,,,.: f�/ D EC 2 8 2011 <br /> HALL C(7UN'fY <br /> Vnder perr�lties ot taw,I decfere that I have exarnined this application and Ihat it is,to the best of my knowledga and belief, ue,com .N�g�,qSy4q <br /> 61&o declar9lhat I am dury authprized to sign thls exemption applk:auon,erxi that tha organizetion ownfng Sha abo�re-listed p <br /> in membership or ernplayment bassd on race,cobr,or natlonel origin. <br /> � <br /> S�g�l A .�,���r►'1 ','�:j-. �I� .t�f /�- ������ <br /> here `,���5�9�,ure T�,a nate <br /> FpR COUNI'YTI�EASURER REC�MMEPIDATION <br /> [�PROVAL COMMENT5: SS �J � �a�-��� <br /> []bISAPPROVAL <br /> ia -a� -�� <br /> Slanature oT County Treasurer Date <br /> FOR COUNTY BOARU pF EQUALIZATtON U5E ONLY <br /> APPR�IIAL COt�M�N7S: <br /> �]p15APPAOVAL <br /> 1. ,� _1.,�-� <br /> tr,��aa s�neu,ra ag1e <br /> Nebra6ks peperVaent Of Hera�we AuMwrized bY Nah•Rev.Stat.§§77-202(1){c)end(d),antl 6a3,185,and 6o-3,189 <br /> 96253�2006 Fev.&2011 3uPOr�edas 96-753•2Wfi Hev.5�2U09 <br /> pL�ASE RETAIN A COPY FOR YOUR RECARI75. <br />