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�^�-�-^ Application for Exemption FoRM <br /> Nebraska Department of <br /> RE�IGNVE frpm MotorVehicleTaxes by Qualifying Nonprofit Organizatians <br /> •To be filed with your�ounry treasurer. /1�� <br /> •Read instructions pn reverse side. �t <br /> ApplicanYs Name Type ot Ownership <br /> � � � � � �Nonprofit <br /> Street or Other Mailing Address �r County � `1 Cvrporation <br /> 8`� w � A' ❑Other(specify): <br /> City State Zip Code State Where Inwrporated <br /> 17��Y'�� ,C1. C ��� <br /> IDENTI�Y OFFICERS,pIFtECTORS,OR PARTNERS OFTH�NONPROFIT ORGANIZATIpN <br /> Title Name,Address,City,State,Zip Code <br /> :c u+-'^ Cc- <br /> �v d: <br /> c+��tc 7 r: � �a l3� <br /> D�SCRIPTIbN OFTHE MOTOR VEHICLES <br /> •Attach an addition�l sheet,it necessary. <br /> Registration�ate ar <br /> Motor Vehicie Make Model Year gody Type Vehicle ID Number aate of Acquisition, <br /> if New Purchased <br /> + a SV S� D S <br /> �xempt Uses ot Motor VehiCle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Hprticultural ❑Educational [`�eligivus �Charkable �]Gemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: �1'ES �NO <br /> PiC.�r lJ�� a.v�B- G��C'��j D3'�r �Ka(1� �m L�...�.v-�d� C-...3 cvw..rvr..�� <br /> , f <br /> ���5 �^� `��� �`�w��, �6� ��C� ��5 u�� r r If No,give peroentage of exempt use: <br /> �_� <br /> �l �,;r.�� " C,K ^'pS. % <br /> G�n�����'►.�] ��e. G4 r.rJ�- �L U P' <br /> Under penalties of law,I deciare that I have examined this application end that k is,to the best of my knowledge and pelief,true,complete,and wrrect.I <br /> also declare that I am uly authorized to sign this exemption application,and that the organization owning the above-listed properry does not discriminate <br /> in membership or e p yment based on race,color,or national origin. p�/���f y�S S, <br /> S 1 g n L.�/l��. r e �a-n �-�-,3 <br /> h Author' ignature 7itle I ��~ /� <br /> Date <br /> FOR COUNTYTREASUHER RECOMMENDATION <br /> �PROVAL COMMENTS: y��'° , �'S$ /T~���� <br /> �DISAPPRpVAL <br /> .�i.��?��� <br /> Signatureo untyTreasurer �ate <br /> FOR COUNTY BpAR�OF EpUALIZATIpN USE pNLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> ����� <br /> u oriz Signature Date <br /> Nebraske Depanment of Revenue Authonzed by Ne6.Rev.Stat.§§77-202(1)(c)and(d),end 60-3,185,and 60-3,789 <br /> 96-E53-2D06 Rev.8•2011 Suparsedes BC•r253-2tlQ6 Aav.5-2008 <br /> PI.EASE RETAlN A COPY FpR YOUR FIECDRDS. <br />