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. ---a_ 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 /> Pct= •Read instructions on reverse side. <br /> •Ap�pligant''s�Naamye (� �j,;t� �I,1 +� / l,� �y /r/ Type of Ownership <br /> WO jfl) �1 USE MSE14 `-17L 1 OF l N rm EFICprolit <br /> Street or Other Mailing Address County Corporation <br /> 3D5 ^ alb. CR-W Y1 <br /> tEKK '1 imL(- ❑Other(specify): <br /> i City State Zip Code State Where Incorporated <br /> b-a rtJb ISc- J 0 6, A 03 (CE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> -PAcTealP2 lilrJr 4k AO) e?3ER-BWK ko3 CA6C-7 WPM Ate GRAND ZstA/h„A )E (0 rt3 <br /> sF�zc TA V-1 hIIYe ' r H,4A-F- j 1p 15e S, Atakcit cr iQA.va J3�tAP..6 tit, tees' <br /> TRr1P6o M1}dt/t STfh/'2,46C 1 750 7C'f2-/L/C rib, A44/10,124� AX✓ (&R V fi' <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> ( lusS,c. [' qg L-"c=kcYes i-r1r • foWPpE-C215Wo2O'19 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational Rligio E,eus Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: IS ES ❑NO <br /> ?JAIL€& CS 45gb `13 41/2Auc. cHUtLcf-f 4QulPJULov1- SutcN A-5 <br /> � ��,p 1k-co �� ��Lf If No,give percentage of exempt use: <br /> Y'2-% S/ V -3 LO p- . ( _i <br /> LK664-&.e- 115 4 E'am't tvO+nm + CµI Lb/lat)5 C 44P `I Mil 2"6 <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 �. / ' S/, /, U � :�„ `�-3—/3 <br /> here 'uthorized Signature - Title Date <br /> �FJOORR COUNTY TREASURER RECOMMENDATION <br /> tPPROVAL RECEIVE I. ,E'��P” ,'eY — S ' 77 --7c-2 <br /> ❑DISAPPROVAL <br /> APR - 3 6Y.Cas...& -.-3 <br /> Signature of ounty Treasurer Date <br /> TREASURECRISMaltfOUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND,NtBRASKA <br /> rJAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • Omer . ; _.,i�!�," ��9,(�o�s <br /> uthorized Signature D to <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev 8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />