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Neen —Z Application for Exemption FORM <br /> braska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. J <br /> szra •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> . f}l,�—PM:115 &Art+er Vey Be heto4ni1 fieni ln0't re 5rrui e5. Znr • is Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> fo1s N. £Jn S-Free+ ?-d. &7X 17103 11AGL El Other(specify): <br />• City State Zip Code State Where Incorporated <br /> ercind 29l4nd AIL (o (r30 a /vet_ <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> PreSielent otnj CIO Carrie_ tAskfd5 Ifoeg5Waetw4/er Ave , Krcrn/. A)£. fot 7 <br /> I)i e.-President- 9„d CFO :Seel K:+ , 603 La- kit- Street, G•und 2444 , Al &SSSG1 <br /> x See citkdckee 1224 oc 80D <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 /> 1:44d MI Van IF 655 Pt kNee TOP! 1-add-13 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> as indicated?❑Agricultural/Horticultural ❑Educational ❑Reli Religious ®Charitable 0 <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ONO <br /> ( <br /> USeel 4v trcn5eort client-5 to ctwd Ric-. Seru:ce5 <br /> • It No,give percentage of exempt use: <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 d l% VP /CFO 9.50-30 13 <br /> here Auth• ized Sig .ture ----,d---- Title Date <br />, �FFyOORRR COUNTY TREASURER RECOMMENDATION <br /> VAPPROVAL RECEIVED MENTSI <br /> ❑DISAPPROVAL <br /> t'r 2013 <br /> �aia.L-:a4.�L.�, !k®a�L ,.tee,. , , io%1�3 <br /> Signature of County Treas rer (f Date <br /> MALLtaR/HR COUNTY 3OARD OF EQUALIZATION USE ONLY <br /> IrxcASURErtS uPP'a <br /> GRAND ISLAND,NEBRASKA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> ill �-uthorized Signature O/ Date <br /> Nebraska Department of Revenue Authorized by Nab.Rev.Stat.§§77-202(1)(c)and(dl,and 60-3,185,and 60-3,189 -` <br /> 96253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.62009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />