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Isket—z— Application for Exemption FORM <br /> ,_Neyraska''repttment 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 —{''� y (� /1 p` t Type of Ownership <br /> S (10oa 0t(t n&lLSLTle_S OF ( r� I VG lnrflk± s ® Nonprofit <br /> leet or Other Mailing Address County 1� 1` Corporation <br /> City k O o4 4 Sc. Po PeX State 1$Co� Zip Code Stall P II Incorporated <br /> — ❑Other(specify): <br /> C�f-ar c13,5\and NIE-. Lo880 a . 2..• <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Prey Airl-rkehed. <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Modal Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Exempt Uses of otor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural jg Educational ❑ Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classiiffiiccations exist:) • ' ' BYES ❑NO <br /> �K3� �'Q - (. 04J;t-3rcp`` .,L�-t Aq 0 aOf�TIOl'i 4ctir If No,give percentage of exempt use: <br /> �J J <br /> S PDr't cw-r c ∎Sctbtl;4.1 prozra.MS • <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. /n r <br /> sign g . (3,, -r-i frer q-18-13 <br /> here /Authorized Signe a Title Date <br /> • ; COUNTY TREASURER RECOMMENDATION <br /> _ <br /> , ' <br /> b APPROVA CO ' ENTS: �'ti2 AX S--5: 77—Qo Z. <br /> ❑DISAPPR AL JUL 1 8 2013 <br /> �X /'_ 7--fl-%ab/�/ <br /> TREASURERS TM Signature of ounty Treasurer Date <br /> • ••' • `EBRAS ]• ; it•UNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 0 S'.a, _ �f/, i/ ��1 1 / _ - <br /> -uthorized ignature f' la ate <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 />