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---z Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •G G *To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> 0Applicant's/Name,[ /�f,�r /�� �J Type of Ownership <br /> ._-0//rnc/ (!Aoil'h e/ 7/c /li/�Z4/ren _, allonprafit <br /> Street or Other Mailing ddress *4 County✓ Corporation <br /> r ,.Q j.O // 0 Other(specify): <br /> City 1 State Zip ode State Where Incorporated <br /> (IP r ns J Zia 4'E 20 <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Ad ress,City,State,Zip Code / <br /> 7r- ehUerr ,v44y/ (Aa.,,dityce /y/44I /41n,o//Y� 44to.Ji40 <br /> sGr,,CJ�///f9r'!heas.e . iliJi i2i/r'// ,...'J4i /Oa ,PSICc,?9 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year SodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> `-7-i9J,t'ii i99 V4-N /F&T5,3/(>555H&2 7 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational lifl Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if muisple use classifications exist: LP YES ❑NO <br /> • �� a eh 7 r if No,give percentage of exempt use:_ _.. <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. p / / J /J <br /> sign `� IJ.�r : .L l'h 'i/,� !�I/� 2.2 <br /> here Authored Sig :tur' Title Date <br /> R COUNTY TREASURER RECOMMENDATION <br /> Er APPR r r'L RECEIVED C IMMENTS: /+-+iJ°"'7"_ /' 42 Al-CS 9 2"-` �e.2� <br /> ❑DISAP' ROVAL o 'Ma <br /> DEC O 1C c�_.2-937,4 c7)/( -442-41-1 /-;?-4,='.7Z2 <br /> -oki nfil • Signature of County Treasurer Date <br /> MOM HP-!-;.�yS of ,t_, •: •UNTY BOARD OF EQUALIZATION USE ONLY <br /> 9� � <br /> `eAPPROVA COMMENTS: <br /> ❑DISAPPROVAL <br /> • Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.s5 77.202(1)(c)and(d).and 60-3,185,and 60-3,189 <br /> 96253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />