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a - Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> licam's lame Type of Ownership <br /> roe e ra-s ka -4-h A43 a n • 5I ' d Conprofii <br /> tree•or Other Mai'••Address I� /f,�, r-.fI County 11 Corporation <br /> '__ ♦ Qr L ,�..xtel or I ❑Other(specify): <br /> nee. Zip a State a Incorporated <br /> r re,h Slaki0 Al (,ctOI /F <br /> IDENTIFY OFFICERS;DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> T L me,Address City.State,Zip Code <br /> I j i ra• %r : fit+ r r a . . 1.4.E tRrra <br /> nn1 . , - . gar Gfl !MTEil reia�, t:! <br /> Imo► EMOWPn'L'IIIS« _G.7/In fMBINMdMPRIP!1n:+M <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear BodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Ia ,.asaagnir a I MnU t 1.111WIW.11r, <br /> Exempt Uses of Motor Vehicle: �,� Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious mCharitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: EKES ENO <br /> � ; , 1 be, Lt cd by 1-�h, mal Ooh+r6\ amp CN No,gvepecenageof exempt use: <br /> k --r°- spa (+ 11105+1 ��ro y 00_0 l n j kre d �I q <br /> a,v� ; mdI5 ct.A6 -I-D Pin-corers avi ∎ (n 0OQeSnG <br /> avid \0. us 4r Ci-i- 0- rand� Tskknd, hick . �I: <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and belies,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 /> e h, <br /> he Aut prized Signature / ' Title Dla9 <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> [. PPROVAL 6plOnnaTS: ^""/ ". S 5 'IA `'7.- .?n <br /> RECEIVED <br /> ❑DISAPPROVAL <br /> AUGr� � � e-t- i 3 <br /> AUG i 3 4013 Signature of ounty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALLCOUN <br /> TREASURERS OOFFICE <br /> ❑APPROVAL GRAND ISLAND,NEBRA3MMMENJS: <br /> ❑DISAPPROVAL 4011 <br /> 7...��i � _!_, - z ' p d p- <br /> if <br /> IP Authorized Signet' : <br /> Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)end(d).and 60-3.185.and 60-3,189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-200e Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />