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im^--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 /> 0 Applicanq Name �^/,, J Type of Ownership
<br /> I 5 leS ' Ct c t niOS CL c'-ne 7.e c onproBt
<br /> --- Street or Other Mailing Address County'Rom e Corporation
<br /> 22 2 6 A WYAJ � 39( 446 b 6 nz 1$(Gw�! /.e ar02_ Rom ❑Other(specify):
<br /> City Slate Zip Code State Where Incorporated
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,State,Zip Code
<br /> Cc ' t -.etc 723 s_ ±. em--- 1.�. / Ass err
<br /> cD+ree-.-c-- Co,. le3 fc� - llo 111 -uet A- a cz,--4A,s ' o<./r • GXFol
<br /> % , u�c t " •a�—/Sle C I f" Ii[ Le- •�_i.pp:. 1 -,fie ♦-
<br /> >�c 3't.r— 6 Gn 14. ez ,i,44 id-Inc-it) 24110 N a•*L, F-0-,,, e.- frig to leidt:
<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 /> N lOnd ck de 61 L, ¶tor - --+Im1=A3[,24.fl0 IRS Ai 17_ 1010
<br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively
<br /> ❑Agricultural/Horticultural ❑Educational 'Religious ❑Charitable ❑Cemetery as indicated?
<br /> Give detailed description of use,including an explanation if multipllee/use classifications exist: 1 f� e ' DYES ❑NO
<br /> 0•--44./let,le, i., C c k I n e e_Q `\ _R �, 1 f i VS ,J No,give percentage of exempt use:
<br /> s �`-.r� /dJ,-rte (-T- 1c.1 ---kkk
<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,= `�IFC I;t..s 1zlizlI �
<br /> here Authorized Signature ` Titl Date
<br /> FOR COUNTY TREASURER RECOMMENDATION
<br /> e PPROVAL COMMENTS: 4 , ,99"`� r ,.f./S`S 'J'f--Pc.-
<br /> Pd�.
<br /> ❑DISAPPROVAL
<br /> o?' -Aue-m- /6?—./.7-te a_
<br /> Signature of County Treasurer /6?—./.7-Date
<br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY
<br /> APPROVAL COMMENTS:
<br /> ❑DISAPPROVAL
<br /> ! RECEIVED u�l iA Sig aal ae math
<br /> Neoraska apartment of F V Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(dl,and 60-3,185,and 60-3,189
<br /> 96-253-200 Rev.8-2011 de 3- .5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
<br /> HALLCOUN Y
<br /> TREASURERS OFFICE
<br /> GRAND ISLAND,NESRAKSA
<br />
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