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,Y .•:. a7,0/3 <br /> 11.1.eka...-- mLentof Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> ezzazugawil <br /> •Read instructions on reverse side. <br /> elApplicant's Name Type of Ownership <br /> MID NEBRASKA INDIVIDUAL SERVICES INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2536 CARLETON AVE HALL <br /> ❑Other(specify): <br /> City State Zip Code State 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 /> C kA∎r wx o-+. Ivan Klein Po Ik 13 1( G'. l4on .UE 41 so t-1 <br /> V;cat- Ckk0.11- h'oor At- neIA Gral.sn 3801 Rd F. &e(son N6 G89lel <br /> Scc / rr ea.slarev Aker, Cct&k zolh k S+ Ord NE 6ffSG "a- <br /> G Eo Otn.,y.< CO..a.,"pte.11 did M Denver 1-lacf-?ls P. 6870 <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 I Date of Acquisition, <br /> _ _ _ _ it Newly Purchased <br /> o CAT a.!h <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticulturai ❑Educational ID Religious ®Charitable El Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: 0./1\ u.11� exc.(w.5•DelrEl YES ONO <br /> • 10 `ro.nc po cl c1a✓'el op men-Lit, c c $ 4lo`t� If No,give percentage of exempt use: <br /> ;� 1 : v ; dIh�ls amc� Prbv?dr scrur"�Pc <br /> Pa r. a in p (o tl 01/12-%"71 • <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 il d.�oxt 13a , ay <br /> here I Authorized Signature a Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION J <br /> APPROVAL COMMENTS: �.S-,% ,��O a <br /> ❑DISAPPROVAL <br /> �-�4954)o-247-14.- /'r9—i M <br /> •Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISFPPROVAIRECEIVED <br /> • NOV 19 2012 —�s'b1olj <br /> ulhorize Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,139 <br /> 96-253-2006 ev 8-2011 Superse/'APt; YFH9OSH4v.5-2009 <br /> TREASURERS OFFICE LEASE RETAIN A COPY FOR YOUR RECORDS. <br /> GRAND ISLAND,NEBRAKSA <br />