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��i� <br /> �n�---�� Application for Exemption �o�M <br /> Nebraska Pepartment of <br /> REVENUE from Motor Vehicle"1'axes by�ualifying Nonprofit Qrganizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name � Type of Ownership <br /> YM�A �Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 221 E SOUTH FRON7 S7 HALL �Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 N� <br /> W� IDENTIFY OFFICERS,C7IRECTORS,OR PARTNERS OF"I"HE NONPROFIT ORGANIZATION <br /> 7itle Name,Address,City,State,Zip Code <br /> r v� Gra a � J i � � .� 5 / <br /> r ; r 1" ic � s) u/� S u . r, � <br /> r ✓� DY� /`hq� o h ( ' C3' /VA, b <br /> r� ►r � L.�� S�� C�'�`av� /S ca / <br /> i�7 G�3 P ve �ir pr _. � o� r r c Q! <br /> DESGRIPTION OFTHE MOTbR VEHICLES <br /> •ACtach an additional sheet,if necessary. <br /> Registration�ate or <br /> MotorVehicle Make ModelYear I BodyType Vehicle ID Number Date of Acquisition, <br /> 1 if Newly P chased <br /> or ! � S3� Hd P 10 /I <br /> a - r-_ � q 1355 oN�'�!R / I) <br /> I <br /> _.�_ <br /> �xempt Uses of Motar Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaUHorticultural ❑Educational �� Reiigious Charitable ❑Gemetery as indicated7 <br /> Give detailed description oi use,including an explanation if multiple use classifications exist: ES �ND <br /> ��� (/"��f G�� ���P�ksJ��� /l�l �'/.r �O�`4 QN� f No,9roe p <br /> P� r�v� ` P!?c� f7�e� S o� ��cr vh <br /> s d�,� �� � Q� <br /> r� ,�� cau.se avc� � ;ssr�,•� . �� <br /> � � NOV 1 5 2Q11 <br /> Undor penalties of law,I declare that I have examined this apptication and that it is,to the be5t vf my knowledge and beli f,true,complete,p��o��1-y <br /> also declare thai I am duly authorized to sign this exemption application,and that the organization owning the above-liste property do�llE�p����� <br /> in membership or employment based on race,color,or national origin. ��ND ISI qNb,NEBRASKA <br /> s i g rl - �i o.� ,��'.�-s Q�a--- //- /�-�/I <br /> here ,Authorized Signature � .,� /'�__„� Title p �� / �ate <br /> �"'� L--•'wlll b <br /> �OR COUNTYTREASURER RECOMM�NDA710N <br /> [�PPROVAL COMM�NTS: , �—SJ � �°��� <br /> []DISAPPROVAL �..... - ' ` ' - <br /> . i��,dl►'� ..1%a �S � <br /> Signature of County7reasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> �PROVAL CQMMENTS: ...�_.. <br /> ❑DISAPPROVAL <br /> f`��` � <br /> Authorized Signature Date <br /> Ne6raska Pepartmont of fievenue � Aulhonzed by Neb.Rev.StaL§§77-202(1)(c)and(d),and 60•3,185,and 60-3,189 <br /> 86-253-2006 Rev.8-2011 Supersedas 96•253-2006 Rev,5-2009 <br /> PLEAS�R�TAIN A GQPY FpR YOUR RECORDS. <br />