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n 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 /> • ST PAULS LUTHERAN CHURCH ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1515 S HARRISON HALL ❑Other(specify): <br /> City Slate Zip Code State 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 /> S(?n :syOrti Sy/urea Kac+1ssnrn A5-/5- 5 ,2NUl 'mt- (,'etud S4A NE 68fnl <br /> C0u-t1 l Pit>,srd t G7iz.ri /Conk '703 Pon/devosaa Chva-ul is/crud NF_/ deg-0,3 <br /> Cioe€4uc.i'i 1)/K Pees: F-Hlc h PP49L .3,5,17 6-4z¢t%a t An O'N/zJ 2;4.0x4 l f2,f$O3 <br /> Cccev 'l 1 5tesuvev1 Rea kiteresort 31111 /bnec,4urrd Mud. 6-,-nad IskArc MME 6r?ft <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 /> /oy0 -cu 2007 Vert) STiD2 KR3C. 175o4 /0a 1/9- `13-, <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> El Agricultural/Horticultural 1:1 Educational ®Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple)use classifications exist: 1�'YES El NO <br /> /r^eve-i 5/0 0vk^ftOr-9 f'o r' ( -4U -VI R C-'ft U 1*icS <br /> • If No,give percentage of exempt use: <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 <br /> CG <br /> ,seC ../.:777e-0 1124o atAf Cottinri t1-re // - /7-)(9/a <br /> here Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> .l l AI SS 77-.;o.� <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> )?c );_taa. //—i,--.i-7 <br /> Signature of unty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISA• RECEIVED <br /> i <br /> ., _, , ! _ FY3—etNJ <br /> prized Signature ar Date <br /> • 1 9 2012 <br /> Nebraska Depar ant of Revenue Aulhorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Re 8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> HALL..^t!^IT�` PL ASE RETAIN A COPY FOR YOUR RECORDS. <br /> 7RFASt7RERs OFFICE <br /> GRANO ISLAND.NE3RAKSA <br />