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<br /> NVekaDep�anment-of Application for Exemption FORM
<br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457
<br /> •To be flied with your county treasurer.
<br /> •Read instructions on reverse side.
<br /> Applicant's Name Type of Ownership
<br /> 0 GRAND ISLAND EVANGELICAL FREE CHURCH ®Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 2609 S BLAINE ST HALL ❑Other(specify):
<br /> City Stale Zip Code Stale Where Incorporated
<br /> GRAND ISLAND NE 68801 NE
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,State,Zip Code
<br /> E\&c' U,._0„_c.--..... \.. 3:A\:., -_ c----Q--- -� ' ik 5�,9„-c-u.a-'id, e.ar-ics-st, -�,vvc e85c1A
<br /> CL,..,..�-, Cc ac,,.>_xv� -S-..S.Ce Sc� \� 'kItGS v C.,-s4.,r Rye cr,m_-,$- Sc\n_?i �t- L+c -s
<br /> DESCRIPTION OF THE MOTOR VEHICLES
<br /> •Attach an additional sheet,if necessary.
<br /> Motor Vehicle Make I ModelYear I Bod Registration
<br /> ate of Acquisition,
<br /> n,
<br /> yType _ _ _ _ _Vehicle 10 Number Date of Purchased
<br /> - it Newly Purchased
<br /> F-o i& C-3Scj .j LS. 'SZ -.)&Cxay -.z. \)u-. "Sir-%.S.3%\-515 CIO \1\R\ C2)\\"\\zv la
<br /> c-o«y 5c log ecv. `, aco■-A a------, �.k-.. t 5u L-1LtI,S.a1-5-11,5
<br /> 1 G N'C S..-?c_..,- G, sscc AcV'\R -t-k SrZ.,dc AA,..-. '-G 'IS ViG'n �2-?,...:Ac,yk'Sc.0
<br /> W<.._-st:. ck-t-'9.= -a oc_ L\t-:\:k,.�-CC-db\mac :u-Luc ti--Ss"is-S, C\`� 5'A
<br /> Exempt Uses of Motor Vehicle: l�,, Are the motor vehicles used exclusively
<br /> y,
<br /> ❑Agricultural/Horticultural ❑Educational L Heligious ❑Charitable ❑Cemetery as indicated?
<br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO
<br /> \E-«--s�o irc,,QAa) S,��QA e5 1`� ec-�'-‘.,-++=c' 'c 0 V E S _ If No,give percentage of exempt use:
<br /> III \ \O c
<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 �, ,.�v� �.Aav\vz
<br /> here IA- ed Signature < Title Date
<br /> 1 RECEIV FOR 2OUNTY TREASURER RECOMMENDATION
<br /> [r A PPROVE L i'( y COMMENTS: / 20'4'' APs.S '77-.702.
<br /> "in V 2 6 2012
<br /> ❑DISAPPROVAL _
<br /> HALL COUNTY i 4t Ii aG-.1.4g-
<br /> TREASURERS
<br /> OFFICE Signature f County Treasurer Date
<br /> GRdNfl ICU pN
<br /> OUNTY BOARD OF EQUALIZATION USE ONLY I
<br /> [APPROVAL COMMENTS:
<br /> ❑DISAPPROVAL
<br /> 0 Authorized Signature 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.
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