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israak�enr t of <br /> for Exemption FORM <br /> RE VENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457•To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> 0 Appp�lliqic//ant's Name ( Fy/; Type of Ownership <br /> //f1LEi3DI'Jet L// �r G4ir/r7fQ / Ce f/kr 14�`Nonprofit <br /> Street or Other Mailing Address / �® County t Corporation <br /> 5 // Latcl Trial_/y //41'6-.! // B// ❑omer(specify): <br /> Zip.5'yvaT ne ,L—5/ 4- p /y tats /G igt5 State Where E mwared <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code /� <br /> A . 'v .c. A %/ F .: ( Y . i- -%6-'1 _r, ./ II 6;1' /f _ , , jf ,rair <br /> fit JWi '►Ali7refilJf// J_�EsiarriJJ/i f!f ,g <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Data or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> U Newly Purchased <br /> cyp/// Ve - /T7, 1W yabarba), iGNFV/`Jf9iF99flJD 12PZrs/f1g <br /> Exempt Uses of Motor Vehicle: .rx Are the motor vehicles used exclusively <br /> 0 Agricultural/Horticultural 0 Educational %Religious 0 Charitable 0 Cemetery as indicated? <br /> ''jGi`vee�detaiilled description of use,including an explanation if multiple"u see classifications exist: ;OYES 0 NO <br /> �/ �°{// r' eh/de- /(//// I'e- A'eel .> 7��� fAept If No.give percentage of exempt use: <br /> f�hH1 z 71/0/ 'riven Goa gc//al e , % <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 /> atAlISLII/I ./f g, , _P2 Al rf;44d*P 1.20:6/.y <br /> here Authorized Signature Title Date <br /> FOR COUNTY TREAASSUURRyERRRR_ECC,O�M}MEN�DATION <br /> APPROVAL ' RECEIVEDMENTS £-�— - -`�" At"d ,14 4 <br /> , , - 77f - <br /> 0 DISAPPROVAL <br /> • AFAR - 1 POO be 3-s'-i3 <br /> ! ' Signatureof Treasurer Date <br /> f 1�K IXJDR�UNTY WARD OF EQUALIZATION USE ONLY 1 <br /> ORAND ISLAND.NEBRASKA <br /> 0 APPROVAL COMMENTS: <br /> 0 DISAPPROVAL 5 S <br /> • iriYulhodzed Signature Date <br /> Nebraska Oeparbnent of Revenue notarized by Neb.Rev.Stet lf§77-202(1)(c)end(d).and 60-3,165,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.P-200S <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />