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:� Application for Exemption FORM <br /> Nepra&ka Pepartment af <br /> R�ENUE fram Mator Vehicle Taxes by Dualifying Nonprofit Organizations 457 <br /> �To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Ap licant's Name , „�� Type of Ownership <br /> ` '� 1 ' �lonprofil <br /> Street or Other ailing Address Counry. Corporation <br /> �'"[� �-�' ❑Other(spBCify}: <br /> F �ty State Zip Gode State Whar�Incorporated <br /> ;�.v `� � �- � <br /> IDENTIFY qFFICERS,DIR�CTORS,DR PARTNEFIS pFTHE NONPRRFIT ORGANIZATION <br /> TiCle Name,Address,City,State,Zip Gode <br /> �"�.� � <br /> D�SCRIPTIDN OFTME MOT�R V�HICLES _ <br /> •Attach an additional sheet,if necessawy. <br /> Registra#ion Date or <br /> Motor Vehicle Make Mpdel Yaar Body Type Vehide ID Number Date o}Acquisition, <br /> if Newly Purchased <br /> �. - <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaUHorticultural ❑Education�l �Religious �Charitable ❑Cemetery as indicated? <br /> Give detafled description nf use,including an explanatinn If multiple use classiiications exist: �YES �NQ <br /> f ' r ��V <br /> ��� '�� VlJ�� 1 �C/���V�Y � �� �Q �� ����U�i�e U` If o,gi�e Per f� <br /> % ; <br /> w�e��s -� --4�he � I�er1� ��d� �is�lpl� i�e c�G�.�{s <br /> C� r�e�� . ��l�I � 9 2oi2 <br /> HAI_L Cc9 N <br /> Under penalties of law,I declare that I have examined this epplication and that it is,to the best of my knowledge and belief, ue,com "� .`KS�FFICE <br /> also declare that I am duly authonzed to sign this exemption application,and that the organization owning the above-listed p .N�BRASKA <br /> in membership or employment based on race,color,vr national origin. <br /> < <br /> S I C,�11 �-,r1�,� ��--_ � _ <br /> here uthorize Signature Tite Date <br /> FpR COUNTYTREASURER 1iECOMMENDATION <br /> �PROVAL COMMEN7S:� ���� ��� ��� <br /> �bISAPPROVAL � <br /> � .�� __ --- <br /> Signature ot County Treasurer Date <br /> FOR CDUNTY BpAR�OF��UALIZATION US�ONLY <br /> �APPROVAL CDMMENTS: <br /> �.,,� <br /> �DISAPPROVAI� <br /> � � <br /> uthorized Signatur te , <br /> Ne4raska�epartmant of Revanue Authorized by Nen.Ree SteL§§77-202(i)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.5-2011 Supersedes 96-25a-80o6 Rev.�2009 <br /> PI�ASE RETAIN A COPY FOR YOUR RECOR�S. <br />