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�-,--�� <br /> '�^-�-- Application for Exemption <br /> Nepr2ska�epartment of FOR M <br /> �1�EN�E fram Motor Vehicle Taxes by Glualifying Npnprofit Organizations <br /> ..,. � ,_ _ •7o be filed with your county treasurer. /O�7 <br /> •Read instructions on reverse side, 't <br /> Applicant's N e ' <br /> , � � � �` Type of Ownership <br /> O O `�, S ' Nonprofit <br /> Street or Other ailing Addr C unty <br /> � � • Y+ �1 ( Corporation <br /> �� State ❑Qther(specify): <br /> Zip Code State Where Incorporated <br /> �'r � N.� LogSo 1 � � <br /> IDENTIFY OFFICERS,pIREC70RS,OR PARTNERS O�THE NONPROFIT ORGANIZATION <br /> Title Name,Address,Gity,State,Zip Code <br /> ❑ESCRIPTION OF7HE MOTOR VEHICLES <br /> •Atkach an additional shee�t,if necessary. <br /> Registratinn Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle Ip Numher �ate qf Acquisition, <br /> if Newly Purchased <br /> Nr` i�.h L, � Z <br /> Exempi Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> �Agrioulturel/Horticultural �Educational �Religious Q C aritsble �Cemetery as indicated? <br /> Give detailed description of usc;,including an explanation if mulYiple use classitications exist: ES �Np <br /> �ro�s i C�s p t.1.b��G`1`t�0►.rc�s r`�'0►,�i 6�,��- <br /> ����` \� _ �; � �� v, If No.give percentage of exempt use: <br /> �� �r1QJ�f , �.Q��d � �.�.� I <br /> �u.b 1��.u,�-fh,� ��. C�. <br /> Under penaliies of law,I declare that I have examined this application and that it is.to the best of my knowledge and belief,true.comptete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed propeRy does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign ��M j� <br /> here orized Signature itle pa�� <br /> FOR COUN7YTREASURER RECdMMENpATION <br /> APPROVAL COMMENTS: ��� _„ d+Z� <br /> /V�S �7� � _ ..._�� ......... - <br /> �DISAPPRbVAL <br /> �.�,p�y'..l� <br /> �Signature'o��C unryTreasurer <br /> Date <br /> FOR COUNTY BOAFiD�F EOl1A�I�ATtON US�pNLY <br /> ❑APPROVAL GOMMENTS: <br /> ❑dISAPPRQVAL <br /> Authorize ignature Dat� �`� <br /> � <br /> Nebraska qepartment of Revenue A�rtnorized by Neb.Rev.Sta�.§§77-202(11(c)antl(tl),and 60-3.185,and 60�3.189 <br /> 96-253-2006 Rev.B-2011 Suparsedes 96-253-2D06 Rev.s-2o09 <br /> PLEASE R�TAIN A COPY FpR YOUR F�ECpRDS. <br />