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0W/3 <br /> an--=— 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 /> cmatErsmassa <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> • CENTRAL NEBRASKA HUMANE SOCIETY ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1312 SKYPARK RD HALL ❑Other(specify): <br /> City State Zip Code Stale 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 /> re m t— ,s a •issler�,. 11 : .- la !• 'rated lcfamtc( IOC- �L�?�fgc30/ <br /> et _ r r M a_- a e Y• FI !1. . art - iffil itr [3•D� a <br /> FRINIMIIMMININ La-LA r'1 'e e. ft a t _attne r Erman lsCixart��t'!0 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> I Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> r.� if Newly Purchased <br /> ►�► �� boo ! �'i1L� eG •• y ' <br /> Exempt Uses of Motor Vehicle: k--,� ' Are the motor vehicles used exclusively <br /> ❑AgriculturalMonicultural ❑Educational ❑Religious Charitable ❑Cemetery as indicated? <br /> Give detailed descrip on of u e,including an explanation it multiple use classifications ex' t: I DYES ONO <br /> ��pyt kral` nt�Ei4t�mo4.ne Soc,, t an 0l 4�Ih-toc� CIO vt ro <br /> Alt y I Y U vs t . 1 1.e s c Yeh 1 C} $ �A D\-k r a-1 I t r-car If No,give percentage of exempt use: <br /> a v p_n s p /o rrt k h c) i x-tn '� m ,c&(�sI Ck h e( t 'Q m..`E it -�C>r g <br /> I05+1 s rc�y p V\ o •: njurcd 6. - arc1 ,c?r�-�oretS <br /> C ;a-m oar (_ .rok..hJT9lan d }10-1 I Co. n-h i v & Odes <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 . 0,,o.k' ' oat -'fit% P,ecL.e /).eL, II <br />• here 'uth• ized Signature Title Date " <br /> RECEIVED COUNTY TREASURER RECOMMENDATION ,.1 <br /> APPROVA •eECEI ED COMMENTS: �"J ,-?s s ry7�c.2- <br /> ❑DISAPPRC VAL r,r., i ,., o <br /> � z.<?–/9- /.2 <br /> HAt I COUNTY Signature of County Treasurer Date <br /> TREASURERS OFFICEE2R CO JNTY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> �i--....-z:- _ 7i:-� ' /l! — /_���3 <br /> Authoriz-•Signatu =Or Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(16c)end(d),and 603,185,and 60-3,169 <br /> 96-253-2006 Rev.5-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />