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_ <br /> - le%iz 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 /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> irod Samaritan Society Grand Island Village ®Nonprofit <br /> or Other Mailing Address County Corporation <br /> 4075 Timberline Street Hall <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 South Dakota <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> cec A1fACPied <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> N Newly Purchased <br /> Dodge Ram 2001 regular cab shortbox 1B7HF16Z815707690 12/27/12 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural El Educational ®Religious ®Charitable ❑Cemetery <br /> as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES ❑NO <br /> •ciliUse uling and picking up parts, furniture, appliances, etc. If No,give percentage of exempt use: <br /> ty <br /> ow Removal <br /> Hauling and picking up landscaping materials, plants, etc <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 1/\ / -� Administrator 12/28/12 here I AuthCADA: <br /> ignature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVED COMMENTS: ^"' .1124N 'r'ss 77- ige"a' <br /> :Z w3 <br /> ❑DISAPPROVAL ,p )I _ 2 91 <br /> „S/ /-2-.•3 . <br /> HAIL COUNTY Signe ure o aunty Treasurer Date <br /> . R'7,su nr RC OcC1re <br /> CRA?t)i S'.AND,NEBRASKA FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> 1411 APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • sire, ._21 /—Aritagf.4 <br /> _ <br /> uthorized- ignature Er Date <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 />