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-70/,3 <br /> t^'-z Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> el Applicant's Name Type of Ownership <br /> NORTHRIDGE ASSEMBLY OF GOD El Nonprofit <br />• <br /> Street or Other Mailing Address County Corporation <br /> 3025 INDEPENDENCE AVE HALL 0 Other(specify): <br /> City State Zip Code Stale Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> eAsrn(z -MARK- OPER-5ECIC. -(03 SA6EWoo0 Ave 6RA+t. 151,nab NF 68803 <br /> GR4-7ARil comet sq.iR.AF — (615 9 R27N(b2 G1?p.go =Si4N Ad. eom 3 <br /> iAER5NRf� MAU. S�T'AND146E- 150 TERJGE'k-b, Mtge RA, Art 68'f ? <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make_ 1 Model Year 1 Rody Type Vehicle ID Number Date of Acquisition, - <br /> if Newty Purchased <br /> Fotat=. aon Ecotrot,Ft 0.4440. 1 PS SS3/L2-ebs2.5'17¢ <br /> form 1190 ctv8 iv/WO E3Sb- Ira T5'31140 SH13/900(. <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticulturai ❑Educational Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist ES ONO <br /> �� �` /� c,(„ n __ 2 If No,give percentage of exempt use: <br /> 440$�" � 1^^ N YC• /��w� <br /> re.P;pi OVA— <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and belief,true,complete,and correct.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 /> in membership or employment based on race,color,or national origin. <br /> sign a, f� - 0.. � PAAL--/(2./ta-nLeiat // —9/t- <br /> here uthonzed Signature Title Date <br /> I R <br /> �• FnR,COUNTYTREASURERECOMMENDATION <br /> E PPROVcL t•+CEI Y l�.rr� COMMENTS: . 'ySS rr7–aOa <br /> ❑DISAPPROVAL ^012 _ <br /> i <br /> p__ i§ G4 2S .. //-.r.7-,.� <br /> HAI.t COUNTY ( S Signature of County Treasurer Date <br /> CRA2;r is:>>r,;=,,NE.9 izASIUFOR OOUNTY BOARD OF EQUALIZATION USE ONLY <br /> ®APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> e-_. / e _ ,-ice J—M o/J <br /> Ihorize•Signatur- Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§77.202(1)(c)and(d),and 60-3,185,and 60-3.189 <br /> 96253-2006 Rev.8-2011 Supersedes 96253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />