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37 0 - ass') 40/3 <br /> - • <br /> ink^----z— 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 /> Applicant's Name Type of Ownership <br /> IGLESIA DE DIOS EBENEZER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2228 N BROADWELL AVE PO BOX 486 HALL ❑Other(specify): <br /> City State Zip Code Stale Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code 9 <br /> ,r t.: - C2 ;2: f) d- Ali _ ..._. sr .e.; 4 ZJ• <br /> C I Sr Prrirarrit /G /// 4-a APATESVC"WIFIZfr <br /> •,-' -r- La 4z . 6 n'cre:. _29/4 Ps rte..- jrn t air //5 .....n lase.. <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make I Model Year _ Bo _ _ Registration Date or <br /> dY Type Vehicle ID Number Date of Acquisition. <br /> if Newly Purchased <br /> 3) O,D6 199 7 I/an 2/3,s/,✓133s yv b»sa, <br /> lS/rebird 2000 'R 11.55 9BH1hKCTh+13f Fan 196- <br /> 91011e4a- v0 q c'ldfxrr :1N-IriFA3ksf15plit%f <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> as indicated?❑A riculturaVHoniculiurai ❑Educational elf ious ❑Charitable aWe ❑Cemetery <br /> Give detailed tlescript�ioJ,9�of used,Including an planatio/t if multiple use §ijicatlons�e7xist: M/ FITS ❑NO <br /> e. Urft. ,rWl.e U TS V1 /!"L_rfT .0 r <br /> • �v Y/ If No,give percentage of exempt use: <br /> .� .pvs1 iS A R%.•J 41aa- ftr 5re -/ to 7 <br /> Under penalties of la 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 l am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in me�aben Ip ployment based race,color,or national origin. <br /> sin // / / <br /> sign ///29 i Z__ <br /> here 1 Authorized Signature Title Date <br /> ECEIVf•r•n1 F�R COUNTY TREASURER RECOMMENDATION <br /> [IWPRAVAL LFrr qC'V CU COMMENTS: t .n a " /�ti y5-S 77--.QC. <br /> ❑DISAP'ROVAL NOV 2 8 2011 �. <br /> V Cam" ��-✓.7 <br /> HALL <br /> SURERSNTY County TREASURERS OFFICE Signature of County Treasurer Date <br /> a,,rt,,NO iat.HtJD,14CuRA0161 t co(COUNTY BOARD OF EQUALIZATION USE ONLY <br /> ,JAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> Mori .• ignature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(11(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 />