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� �, ��— <br /> ,�e���- Application for Exemption FORM <br /> Ne6raske DeparCment of <br /> REVENUE Yrom Motor Vehicle 7axes by Dualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> ApplicanYs Name Type of Ownership <br /> CENTRAL N�BRASKA CHILD ADVOCACY CEN7ER �Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 721 W KOENIC� 5T PO BOX 844 HALL �pther(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISL.AND NE 68802 NE <br /> IpENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NpNPROFIT ORGANIZA710N <br /> Title Name,Address.City,5tate,Zip Code <br /> � . _ � �v�� ^ C l, 4�� �r <br /> � Z� VV <br /> _ '2CVC i� S� LP v <br /> C � s ir <br /> rc�Gi �L�.i,L-li - 'reC10� <br /> DESCRIPTION OFTHE MOTOR VEHICL�S <br /> •Attach an additiona)sheet,if necessary. <br /> Registratinn Dete or <br /> Nloto�Vzh�ue Niuke .....�c:*�Car E-dyTyp� L'ehicle:�N;:,��..�� C^tc af^^N::^iEos, <br /> if Newly Purchased <br /> —c r� x D� i10 r�S P GP FA��t�' PU�� ►Gl G <br /> Exempt Uses of Motor Vehicle: Are the mofor vehicles u5ed exclusively <br /> ❑AgriculturaVHorticultural ❑Educational ❑Reiigious �Charitable ❑Cemetery as indicated? <br /> �� <br /> Give detailed description of use,inciuding an exptanation if multiple use classifications exist: L�Q� j s (�(�«'� `��J �UQ I IZI Y�S �NO <br /> !'S <br /> tti -{�•�e �eiev�v� Cou�-��S C�v�-c.d ►,y �-1��. CWIt�-�c.Q. �rCl�rusk�tc�;1�1 �s <br /> ✓� �� �3-� Y1'l.C.i�'C7�4�f �'"l.E � d(.S C`l.t.'?�- �.G� ef V�I If No,give r������r� <br /> �-�I�c�.�,� c� �� ��. <br /> �w� �.�;,.�-� ��i���:ys ��, P i� �v� c'��c�fi�f. w� cd� �isv <br /> h��p � �nSj��;��--t z�� V)�1�r;� 5 w�C� i�!L'tr� -�{`fC��((�?� ��l�C� �rQV 3 0 ���1 i <br /> vv�.�i��� � <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and beli ,true,compl �@, UF��C� <br /> also declare that I am duly authorized to sign this exemptipn application,and That the organization owning the above-listed roperty��9,k_�1i�qri��te�;:�P�•,�,yi;,; � <br /> in membership or employment based on race,color,or nationai origin. °"'—` ""'"""� <br /> sig n � 1�C(�-�- �ei°�.d�� I��PC�� i� 2..� ;J�.... <br /> here ��t rized Signature Title Date <br /> I � � FOR C4UNTY7REA5URER RECOMMENDATION <br /> �PPROVAL COMM�NTS: ����� �'�'J <br /> ❑b15APPROVAL <br /> � `Z <br /> � ��I�/.�rlA.�l.1'[�i � .. . . ..� . 'N� J/ <br /> �Signature of Couniy Treasurer Date <br /> FOR COUNTY BQARD OF E�UALIZATION USE ONLY <br /> �PPROVAL COMMENTS: <br /> �/ <br /> ❑DISAPPROVAL <br /> I-�-/� <br /> Authorized Signature Date <br /> Nebraska Department of Revenue Au�horized by Neb.Rev.Stat.§§77•202(1)(c)and(d),and 60-3,185,and 603,189 <br /> 96-253-2006 Rav.8•2011 5upersedes 96-253-2006 fiev.5-2009 <br /> PLEASE RETAIN A GOPY FOR YOUR RECORDS. <br />