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<br /> tCD---_-- 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 i .-- Type of Ownership
<br /> IITEHAMA SHRINE/CENTRAL NEBRASKA SHRINE CLUB "2' kin r 404 6,Gt P, c ®Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 5575 S ENGLEMAN RD HALL
<br /> ❑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 /> '-mss i3.rl it7tp6, A3c,t I 5t /�xy par�iPIcl.nilc/win/ cadJ` J
<br /> SQC. /Jc1 /A:9c f-II�'t/ ' c:c 1,• f2i r .,=d j f ry p/4 /c.A.1- ' 7
<br /> j t'tt( S fi'!r/(16wi L-,rser ,s-s- 7( 'i /417 tot.<aI lid L,ant/-Ts/gAU.,v/ c eaj,t4)5
<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 /> DoJ ra Ilem ; Of) l 1?-khp is-AD QuctE Il)7N.4/RN).C'7/ it" •Rri7 ;'i
<br /> Exempt Uses of Motor Vehicle: - Are the motor vehicles used exclusively
<br /> ❑Agricultural/Horticultural ❑Educational ❑Religious f3 Charitable ❑Cemetery
<br /> as indicated?
<br /> Give detailed description of use,including a explanation if multiple use classifications exist: F'ES ❑NO
<br /> Ld S e& iv ;7,t i1 rni. //p e,T.%.Vr 7A j v - /car h 75 "4 -, C's.. -.1j.
<br /> • i}• V .` ✓ If No,give percentage of exempt use:
<br /> �/Fr.
<br /> c
<br /> am(: e•-• S al cit ec /'`c:c/?, 'fe s ft' 2/1,/c, 7 yr/1 0(/ 1y r,A/
<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 />'
<br /> sign j al i`, a 77,-e s. .- /i,/� >iL_
<br /> here I Authorized Signature Title Date
<br /> I FOR COUNTY TREASURER RECOMMENDATION+A/
<br /> SS
<br /> COMMENTS: 9 A A/SS 77— ..2.±,�-'
<br /> ❑DISAPPROVAL
<br /> � Y ,h. ii-.ao -a
<br /> Signature
<br /> of County Treasurer Date
<br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY
<br /> .APPROVAL COMMENTS:
<br />•
<br /> ❑DISAPPROVAL
<br /> RECEIVED , i . .7.,- /-�.P-2o.j
<br /> . NOV - thorized Signature Date
<br /> Nebraska Department off venue NO y 2 0 20IG 7q Authorized by Neb.Rev.Stat.§§77-202(1)(c)and U,and 60-3.185,and 60-3,169
<br /> 96-253-2006 Rev.6-2011:Jv ersetlas 96-253-2006 Rev.5-2009
<br /> PLEASE F ETAIN A COPY FOR YOUR RECORDS.
<br /> HAi.I.COIJN'fY
<br /> TREASURERS OFFICE
<br /> GRAND ISLAND,NESHAi'SA
<br />
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