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�en.-----4. - Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be tisd with your county treasurer. <br /> •Read Instructions on reverse side. <br /> glipplicant's Name 'F' 1 Q Type of Ownership <br /> (�t; J. ' Ncbra5 La. lncl t4cLo—1 5ei—Vjre. S 4 Nonprofit <br /> Street or Other Mailing Address (k County l Corporation <br /> .Z- 3 6 Cap-1.ekor. NU t... 14" `` <br /> ill Other(spedfy <br /> City Slate Zip Code - StateWhere Incorporated <br /> G raxn.a. t z l ow,t, N E X 2 8 0 3 N <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tale Name,Address,City,State,Zip Code • <br /> Ci�o.:rnnan. Tvoa 10E1n Pa ex 13 t;&kon, ALE 1 8840 14 <br /> V-1 cc ChatrMttn mold 3ro��+ 380 Al A NP soq .U6 /. 7S4I <br /> • Se.- /Trewsttirer Allen Cencak ;on I'C Si Orcl' NF1 6 8841 <br /> e, E 0 [11 awe. (rr x.tbcll 214 N header Nash n 3s Al,E- 4 8 90 r <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> • •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year SodyType Vehicle ID Number Date of Acquisition, <br /> _ if Newly Purchased <br /> C 1rcls lcr 2,011 4 •r A Tou.rtng 42C.HRc1866cR3512]1 e-ia-13 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural El Educational ❑Religious Charitable El Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 1 1 ig YES ❑NO <br /> TO r r.6 r Orr AG V'G(o P1 r O e_njt 0.1 t 71 Jett Serb •L If No,give percentage of exempt use: <br /> • i n b-1vtAuo..t5 a-vti pro VidC Set-1(ice S <br /> For e-rr, plod trnta_n+. <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 1 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 /> An B r <br /> here • a •.. a r , •� Title t C Date / 11[b Authorized Signature <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> '- ^t�c v �s!•,s47 'ir 77 so a_- <br /> [4�APPROVAL COMMENTS: ^'� <br /> ❑DISAPPROVAL VASt•riSSN'ONViSI ONVLio 1 <br /> 30�AlNSf103JLITnSvV3a1 /•,..neca0V €'-• •q*I—/.p <br /> • Signature of County Treasurer Date <br /> Cu i7 0 4 N6QR COUNTY 30ARD OF EQUALIZATION USE ONLY <br /> El APPROVAL A a� 7 COMMENTS: <br /> ❑DISAPPROVAL -O3AI333 I <br /> e rlsi. 1 psPi _ -'i'i%I! <br /> • Authorized ignature ' Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and Id),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 />