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ekn--L-- 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 /> Ap licant's Name. (( ( Type of Ownership
<br /> (;Inef-t'la °S ild AY tit li lATLI- TEY" HLCr7:t,avt. i tZ Nonprofit
<br /> Street or Other Mailing Address J // .y� i County ( Corporation
<br /> Lac \V; . 7 r•t o `-ST', 4' 1)- c- B rs, re , t 1 ❑Other(specify):
<br /> City I State Zip Code State Where Incorporated
<br /> C-i"e.i%tc( :L lciIIet NE bgg�;2 ivr
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,State,Zip Code
<br /> )f'rfvMt '2RiP,frvirrS Pros 7284- tc _Di vistot-) (41 NE b`& S 0! 3
<br /> intkxr) eicr, V.-P. 52i5 3+ - A✓1ri re_cc,<;
<br /> (;-,- , =a 1.3 `- C QSC
<br /> , 3
<br /> T tLv1S -uSSel ma ,lr ref trStir: : It Pct.lyd cst. br 6r t�,e_ 6:_.,& :ir3
<br /> JULt�e. E-Jcad -a-are+a3 2 i q1; Ni , t,o
<br /> re l C-;.T NF hCs£s(\
<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 /> if Newly Purchased
<br /> 1--)evvt e nla(( t'- 2C)1 3 Z whet- l , Oper7 ,3/z,t 1 r z,
<br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively
<br /> ❑Agricultural/Horticultural ❑ Educational El Religious tB Charitable ❑Cemetery as indicated?
<br /> Give detailed description of use,including an explanation if multiple use classifications exist: 9ES ❑NO
<br /> t'cr— j}2'r'lVlG Arid 4`VGL�.ctivt S Plc CA�'7�Id V t 3. --4-c et.,L�1 e; If No,give percentage of exempt use:
<br /> vi, it i,) C5i-VA r'ei3t_Icci--1 atLs r
<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 �/L9y( j �' .-/Lim - 6.)go , D., ,r i-t) r s/4/5
<br /> here AGihorized Signature Title Date
<br /> /// FOR COUNTY TREASURER RECOMMENDATION
<br /> [L]PPROVAL RECEIVEDMMENTt: ,asw M°5:.51 77-`
<br /> ❑DISAPPROVAL
<br /> VP: 2 2013 .--P ,or Q-4 .s'- --i3
<br /> •Signature of County Treasurer Date
<br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY
<br /> PALL COUNT!
<br /> TREASURERS OFFICE
<br /> ❑APPROVAL GRAND ISLAND,NEBMKA-
<br /> ❑DISAPPROVAL
<br /> / / rthiceel
<br /> uthorized Signet ne- Date
<br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,165,and 60-3,189
<br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2008 Rev,5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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