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���-� Application for Exemption �o�nn <br /> Ne�r�ska bepartment Uf <br /> REVENUE �ram Mator Vehicle Taxes by Qualifying Nanprofit �rganizations 45� <br /> •To be filed with your county treasurer. <br /> •Read instructions nn reverse side. <br /> Applicant's Name Type of Ownership <br /> r � 1 / <br /> 4 �i ,{ � Yl <<f �TL l !.—���w��-v t'�.i��'c. i� .�"�:4 9C �J1_� 4L�� in Y-C. �Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> �r�;7 .� !� "�' '� �p,� �/a� �Qther(specify): <br /> City / State Zip Cvde State Where Incorporated <br /> C r r�x�,� �� ��r�af N}_ � �'�� I � E <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> �-�t�� Name,Address,City,State,Zip Code <br /> � ,,- s p � � 0�6 -z. �� 3��e. ,�t r� � .�� d <br /> c� - �� �re�s��,-cr Ro�,�, K'� ► ar� 33.3� L.� �,,,�... 1� Cr . L;., _G� N ,E ��sd <br /> DESCRIPTION OF1'WE M�TOR VEHICLES <br /> •Altach an additional sheet,if necessary. <br /> Registration date or <br /> MotorVehicle Make ModelYear BndyType Vehicle ID Number Date af Acquisition, <br /> if Newly Purehased <br /> vr `a �a�° c�_ 1=t V �' L' � 'IS� caa 9e�SD <br /> �'r�-� r� F 2 <br /> Exempt Uses nf Motor Vehicle: Are the motor vehicles used exclusively <br /> �Agricultural/Horticultural ❑Educational eligious ❑Charitable �Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classitications exist: YES �NO <br /> 1 � t 5 u a-�r 7r��.��.f 3�. �-�r-�vu� I �c ra s s <br /> 1j 5�o� � y � %? �� b � If Na,give percentage of�xempt use: <br /> J / <br /> 2r✓�� )n ' � � S '� S �.� � C_�Gi Y �-�1�.F S� — /O p �6 � <br /> s"��`�"�. S.c.�� � <br /> ��'SLtWi '�4'.'1^�7 4n'�c-�S <br /> s <br /> 10�.� r � �, <br /> Under penalties ot law,I declare that I have examined this application and that it is,to the best of my knowledge and belief,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this e�mption application,and that the organization owning the above-listed property does not discriminate <br /> in member5hip or mployment ba5ed on raae,color,or national origin. <br /> S�g h y -c�f�'-, ,� ;��-�c�`t SYT�4,.1 v.�•,��,'� °-� � 15--- !2 <br /> here Authorized Signature Title 4ate <br /> FOR COUNTYTREASl1RER RECOMMENDATION <br /> /r�.�'.� '�7 7--��� <br /> �PPROVAL COMMENTS: <br /> �pISAPPROVAL <br /> � � 0� �_ �G -f.2y <br /> SignaTUre of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUAI„IZATION USE�NLY <br /> �APPROVAL COMMENTS: <br /> [�DISAPPROVAL. <br /> uthorized ignature �ate <br /> I <br /> Nebraska Depe�rtmem of Fevenue Authorized by Ne�.Rev,Stat.§§77-202(1)(c)and(d),and 60-3,�85.ana 60-3,189 <br /> 96��53-2�06 Rav.8-PD11 Supersecies 96-253-2006 Rev.5-2009 <br /> PLEASE R�TAIN A COPY F�RYOUR RECpRDS. <br />