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. . X0/3 <br /> +ti^--Z- Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> HEARTLAND LUTHERN HIGH SCHOOL ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3900 W HUSKER HWY HALL ❑Other(specify): <br /> City State Zip Code Stale Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> L—/a 11rCi, #t a ' /✓LSon a I 3 4616 ice y 1. I/ / <br /> '; <br /> t ( _ a -ve, .ataffnent <br /> rmami i ,� sr� :O <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear Body Type Vehicle ID Number Date of Acquisition, <br /> � �pnatant it Newly Purchased <br /> r - r2 Xte.k(Pir (79,4-5 /fo/ea sltTyrfegwte/ // /g-1 z- <br /> G.�L 119 ccr-At/ 16-KOM PI kAi(1 X6.`j; /- 18 =1 Z <br /> Clier/ro ia- /19 sdcbrb/Can etc. 36-NECI co is<7q XC�2i 1g .Z.2'/ ' <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgricultumUHorticultural Rucational El Religious ❑Charitable 1:1 Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: B<S ❑NO <br /> 1--,ts '40 S illt fS <br /> If No,give percentage of exempt use: <br /> • "J <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. ���,,�"1[�� <br /> here Authorized S na,ur �T�/Kea_ �_ _ cj i,(I,- �-11 Dat//- 5 -/ <br /> qF gg ffff���`yg+ FOR COUNTY TREASURER RECOMMENDATION e7 ' <br /> APP iOVAL RECEIVED COMMENTS: ti'/'�07W 4p-✓ /✓StS ' 77 °y O . '' <br /> ❑DISAPPROVAL /� <br /> °WV)° °" //-6-v-ad <br /> It Signature of County Treasurer Date <br /> HALLCOVN I,c,C6 FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TRFMA LCO Qc <br /> , GRA40 6:6 AND,NEERAF:KA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • �/s= C3/3 <br /> Nhorized Signet Dale <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§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 />