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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 Bled with your county treasurer. <br /> cr •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> • EPWORTH VILLAGE INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br />• <br /> 2317 N KRUSE ST HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> XAle Nka`me.Address,City,Slate,Zip Code / . l <br /> rp es.ift.- r /`� Qr: ` SI'CJC&rrf ai �-O_j(_)(`r , ��L-c)t !�-' - <br /> V5c'e if t,--- <br /> WI•PV�"t' (llitih Q.Te-.rw :V�2 TV�i 9ot.wT <br /> Sri re ry 4�( Z v;r.t‘es"....-V i rK <br /> I <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 /> L?or-l-- Newly Purch sed <br /> s-t�r 2-005 rlr-F VaY■fTee4&r 2F- A-5`7 X5 5A(09.7b 0 tit?L°i <br /> CLat/u, 7-003 S111Par-cVar. 1C9N171.03t.123 stl (ofl kit(Ir3 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaUHorlicultural ucational i J <br /> ig-Baligious kehantable ❑Cemetery as indicated? <br /> ,, <br /> Give detailed description of use,including an explanation if multiple use classifications exist: S ❑NO <br /> �{�� P If No,give percentage of exempt use: <br /> y^ow,r p_4_ s-1_0„2“--,4-0 224-1rn.9S <4- Ir--a-1 <br /> C0.. • -ftA-S v "irJ' K._ <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,,coolor,or national origin. (� <br /> Sign � �"�,�<X"� ��— �ceS'Jar r!(t � <br /> Z <br /> here ,Authorized Signature Title Date <br /> - I FOR COUNTY TREASURER RECOMMENDATION <br /> PPROVAL COMMENTS: 4 ,gt, /Cle 11737-c-1 "lf-5'5- '77 ' -gda <br /> ❑DISAPPROVAL <br /> i•Signature of County Treasurer Date <br />• <br /> RECEIVEDhU0 COUNTY BOARD OF EQUALIZATION USE ONLY <br /> pf,ARPRDVAL COMMENTS: <br /> ❑DISA ,PROVAL DEC 1 4 2012 /-Area <br /> HALL COUNTY i'� - __��.� . ! /o/ /A" 2014 <br /> • TREASURERS OFFICE - thorize. ignature Date <br /> GRANO ISLAND,NEBRAKSA <br /> Nebraska Department of Revenue Authorized by Neb.Rev Stat.§§77-202(1)(c)and(d).and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev 8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />