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a---------� <br /> TQBEFIL�nWITH Application for Exemption FORM <br /> vouR COUN'rV from MotorVehicleTaxes <br /> TREASURER by Ctualifying Nonprofit prganizations 457 <br /> •Read inslrucYwns on reverse side <br /> plicanYs Name Counry Type of Ownership <br /> � �� � �� Nonprofi[ <br /> Street or Other Mailing Ad ress Counry Number �orporation <br /> P. 1� �"�b ❑Other(specify): <br /> C State Zip Code State Wher Incorporated <br /> � - � o � <br /> IdentiTy Qfficers,Direcwrs,or Partners <br /> Title Name,Address,City,State,Zip Code <br /> LIST SP�CIFIC DESCRIP7IUN OF THE MOTOR VEHICLES <br /> •Attach additional sheet if necessary <br /> Registration Daie or Date <br /> Vehicle Make Modei Year Body 7ype Vehicle Identrfication Number of Apquisitivn i(Newly <br /> Purchased <br /> L �-- <br /> i4 i-T � (� a-- <br /> :-T � — y <br /> �r % O - <br /> Nature of Use of Moior Vehicle: Are the motor vehicles used <br /> ❑AgriculturaVHorGcultural �Educational ❑Religious ❑Charitable ❑Cemetery ezdusivery as indicated? <br /> � <br /> Give detailed description of use,including an explanation if multiple class'rfications exist: �YES ❑NO <br /> -se4�—r�� ,1� � /n b�\P LY��C7 � � � �.. If No, we <br /> 9 Percentege: % <br /> ��Q�_5_ ._..._ <br /> Under penalties af{aw,1 declare that 1 have examined this application and,to the best of my knowledge and belief,it is correct and <br /> complete,I also declare that I am duly authorizedYdo sig this exemption application,and Rhat the organization owning said property dces not <br /> discrimina[e in membership or emplvyment 6ased on ce,color,or national origin, <br /> sign � '� � _? _ <br /> here AuthorizedSignature Title Date <br /> FQR COUNTYTRFJ�SURER'S RECQMMENUATION <br /> [�'APPROVAL COMMENTS: '�� N 5 S `�'��°�p `� _,.. _,,, <br /> ❑DISAPPROVAL <br /> ►� � �-•-��. �� �y -��. <br /> Sig�f Coun Treasurer � Date <br /> FpR COl1NTY 80ARD dF EQUALIZATION U5E ONLY <br /> `�APPRDVAL COMMENTS: <br /> ❑DISAPPRDVAL <br /> Authorized Signature �ate <br /> I <br /> Nebreska 9epartment of qevenue /wthonzed by Neb.Rev.Stat.§77-202(1)(c)(d),§60-3,185§60-3,189� , <br /> 96-253-2006 Flev.s20o9 Supersedes 9Fr253-2a06 Rev.11-2008 � <br /> PL�ASE MAKE A CQPY�QR YOUR RECORDS <br />