Laserfiche WebLink
X0/3 <br /> • lava-- .- 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 /> Applicant's Name Type of Ownership <br /> • SENIOR CITIZENS IND ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E 3RD ST HALL 0 Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> P I-I-or he J. 115 — <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 /> Rio, Sea:Ana. Zap G3 Van )GN ihrr)BZ3,3(obonS6L4 O(0)Ai 2- <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 0 AgricuituraVHorticultural 0 Educational ❑Religious Charitable ❑Cemetery as ind aced? <br /> Give detailed description of use,Including an explanation if multiple use classifications exist: _ n AYES 0 NO <br /> •—Py vv I JO )e! y Vp�`V b -2' `rtoo -Y S . ) CAD frL&t- g It No,give percentage of exempt use: <br /> LA)illA ,n Wa I I Cov-v`b? <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 Jt_ ' �__%_._ .. 4.i.,,A: {12,e;I / 2 /4'-/ . <br /> here uthorized Signature ' Title ' Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> Q APPROVAL COMMENTS: 1 n-1 a'SS 77-470.2,-- <br /> o DISAPPROVAL <br /> h, `�9v/` `��. cQ.-X, /�_i7 is <br /> ` • • Signature Of ounty Treasurer Date <br /> '•R COUNTY BOARD OF EQUALIZATION USE ONLY <br /> • <br /> IXI A" 'OVAL ( I0 Cu MENTS• <br /> 0DIS'-•PROVAL A�� .S(ll fit' <br /> V O" OY <br /> Ox Whorl Signatur Date <br /> Nebraska Department.-•even-- Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 603,185,end 60-3,189 <br /> 96-253-2006 Rev.6-20t,1 . :odes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />