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`�gn—��� � <br /> w��--�-- Applicativn for Exemption �o�M <br /> NCrbraska Department nf <br /> RCyCNUE fram Mator Vehicle Taxes by Dualifying Nanprofit Organiza#ions 457 <br /> G G �Tq be liled wlth your county treasurer. <br /> - •Read insiructions on reverse side. <br /> Applicanl's Name �� Type ot pwnership <br /> ������ ��� �� �� �" e r`� lonprofit <br /> Street or Other Mailing Address County Corporation <br /> � I� � A� <br /> �Other(specify): <br /> Gity State 2ip Code 51ate Where Incorporated <br /> ,rq (�� S D <br /> ID�NTI�Y pFFICERS,DIFIECTORS,DR PARTN��tS pFTME NONPR�FIT ORGANI�A710N <br /> Title Name,Address,City,State,Zip Code <br /> a�SCRIPTIDN DFTME MOTOR V�HICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Da#e or <br /> Motar Vehicle Make Model Year Body Type Vehicle I�Number Date nf Acquisition, <br /> if New1y Purchased <br /> �. � - y � <br /> Exempi lJses of Mvtor Vehide: Are th i I ively <br /> �Agriculiural/Horticultural ❑Educational Religious ❑Charitable ❑Cemetery as indi <br /> Give dc�tailed descripYiun of use,including an explanation if mu tiple use classificatinns exist: �Q� ' ❑YEA'I� _,p�1��jO�q <br /> C,�r (� ,/►�� �S(Ct►� �-�ra� a MU U1 L 4 <br /> �� Qn(�� ��m �+n�u'• y ��""`�' "" If No,give percentage of exempt use: <br /> �� QYI Ci) �Yn m YY1DYi-!�i 5�'� �r1 Q n�� �.._..�n�t�cOUN�-v <br /> .�- r-e I� Uvsy ha.�ses �n 1�1� p �. �����s <br /> I o arn d fi-o m o�' 8� <br /> �v Av►C� �rC�'Y� 5`�nr�� �D� 1'lOUS�r1oIC� �S �p�rs-�.-r�/�rra 5 <br /> lJnder penalties of law,I declare that I have examined this application and that it is,Yo the best of my knowl�dge and belief,true,complete,and correci.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> ii�membership or employment based on race,color,or national origin. <br /> sign �',��r�.,n � �� �!�� <br /> here Au orize nature Tit e �� 7'—'��./_ a e <br /> .<<_ <br /> FOii COUNTYTREASURER RECOMMENQA <br /> �APPRCJVAI� <br /> COMMENTS: y5S 7T� ���oZ' <br /> []p15APPROVAI. <br /> � �'�.c_.��. � ��a <br /> Signature of County Treasurer Date <br /> FOR COUNTY BOARD q�E�UALIZATION USE DNI.Y <br /> APPRdVAL CQMMENTS: <br /> ❑DISAPPROVAL <br /> � <br /> uthorized Signature Qate <br /> Nebraska L]epartment of RevenuP Authorized by Nab.Fev.Stat§§77•202(1j(c)and(d),and 6D•3,165.�nd 6G3,�8:a <br /> 96-253-2006 Hev.B-2011 5uperserJes95-253•2006 Rev.5-2D09 <br /> PLEASE RETAIN A COPY FDR YOUR RECOR�S. <br />