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riteet....--e___ Application for Exemption FORM <br /> Nebraska Department of <br /> IIEVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> - ' "r' •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> ORPHAN GRAIN TRAIN ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 427 N SHADY BEND RD PO BOX 1565 HALL <br /> ❑Other(specify): <br /> City State Zp Code State Where Incorporated <br /> 1 GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,Citric State,Zip Code <br /> /2q red or' gi-,14prr" .24 oes TC; fL , (✓_r, c _s.-in v) iv- th,yea3 <br /> 1! rer. a" E,�/g 1c) '6' kit.-cc& , �.i4-i ro A.1 ( rc,yS�t,.f1 - <br /> - ,r�.'ge' tZCAI marri-S /roc.c .t'°'.ri zY /v4 dSPeit7 <br /> DESCRIPTION OF THE MOTOR VEHICLES I <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear Body Type Vehicle ID Number - - Date of Acquisition, <br /> if Newly Purchased <br /> I <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist OYES ❑NO <br /> • If No,give percentage of exempt use: <br /> 7 <br /> Under penalties of law,I declare that I have examined this application and that it Ls,to the best of my knowledge and ballet,true,complete,and correct.I <br /> also declare that l am duly authorized to sign this exemption application,and that the organization awning the above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign <br /> here Authorized Signature Title .Date.. <br /> I FOR COUNTY TREASURER RECOMMENDATION <br /> D APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> i'Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 0 ®Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Swig 77.202(1)(c)and 80.and 604,185.and 60-3,189 <br /> 96-253-2008 Rev.8-2011 Supersedes 96-253-2006 Res.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />