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�C�g - C��l � '�r7`�`� <br /> •�,•-�� Application for Exemption Fo�nn <br /> Nebraska i�epartment af <br /> REVENUE from Motor VehicleTaxes by �ualifying Nanprofit�rganizations 457 <br /> •To be filed with your county treasurer. <br /> •R d instructions on reverse side. <br /> � Type of Ownership <br /> App icanYs Name • , � _ <br /> 7 <br /> C (� C Nonprafit <br /> Street or pther Mailing ddress County �Corporation <br /> �� � pG �Other(specify): <br /> City � St te Zip Co State W ere Inrco^rporated <br /> �-� �� o � ,c�. <br /> IUENTIFY�F�ICER5,DIRECTpRS,OR PARTNERS OFTHE NONPROFI7 ORGANIZATION <br /> 7itle Name,Address,City,State,Zip Coda <br /> r ` Z I i � -'� <br /> � �r r�`� i o . <br /> � � <br /> r�_e_. i�r�si��.Yt � <br /> L ' <br /> UESCRIPTION OFTHE MOTOR V�HICL@S <br /> •Attach an addi#ianal sMeet,if necessary. <br /> Ftegistratian Date nr <br /> Motor Vehicle Make Model Year Body Type Vehicle I�Number qate of Acqulsitian, <br /> if NOwiy Purchased <br /> � Zc�c� t� �x� �3 J I � <br /> �xempt Uses of Motor Vehicle: as in�t{ffl���F��� <br /> ❑Agricultural/HOrticultural ❑Educational �Religious ❑Charitable ❑Cemetery � <br /> Give detailed descriptian of use,including an explanation if multiple use classifications exist: , �YES �NO <br /> `l ( , P� Q���� -�� �p��� �5��G� If No,g�9rcenta�oGbkbFnpt use: <br /> `/�'L.tC.d � �. � <br /> I�C�� �"� °d--h � �'�,�:¢' �`. � <br /> C�� � �-- �. i ou , <br /> f HAI_L GqUNTY <br /> �I�Y"1 TF2FASlJRE45 aFFIC� <br /> r�,��a,�� � {�L.�X� 5 y U�'� ���,�,:o i�;�At�'�.NEBP.ASKA <br /> Under penalties nf law,I deClare that I have examined this application and that it is,to the best of my knowledge and belief,true,complete,and cvrrect.I <br /> also declare that I am duty authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment b d on race,color,or national origin. <br /> S i g n �r��T'���7`��c5 75 � /.2_ <br /> here Au orized Signature 7itle Date <br /> FQR COUNTYTREASUR�R RECt]MMENDATION <br /> APPROVAI. <br /> COMMENTS: /�'`� �s S ���J��� <br /> [�DISAPPROVAL <br /> ��.�.�.1� 8`-�- i� <br /> Signature of Gounry Treasurer pate <br /> FOR COUNTY BOARO OF EQWALIZATIQN USE ONLY <br /> APPROVAL COMMENTS: <br /> �DISAPPFiOVAL <br /> �-�..,��2�,�2 <br /> onzed ' nature Date <br /> Nebraska�epartmani of Revenue Authorized by Neb.Rev.S[et.§§77-202(1)(c)and(d),end 60-3,185,and 60-3,189 <br /> 96-253-2�06 Rev.5-2011 Suparsedes 96-253-2006 Rev.�2009 � <br /> PLEASE RETAIN A COPX FpR YOUR RECORDS. <br />