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gigkel.—z-- Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •• •Read instructions on reverse side. iii Applicant's Name / f+ c rr��''77 r }}�� /fir' ' / /� Type of Ownership MI 'uS lE ' io ,n1oc L- c % M o!2 - EeCnprofit Street or Other Mailing Address + _7`,,. �/-�� c County /� Corporation t 5 J. 2 L^ 5 I ' �-1 rg J �J64d_ rT ❑Other(specify): City State Zip Code State Where Inoorgorped 600 / 1L �/1 IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title ,pS,!J g. Name,Address,City,State,Zip Code M4uRio c%a- 1 577 (-k5,9e e tu " DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,if necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle 10 Number Date of Acquisition, if Newly Purchased Exempt Uses of Motor Vehicle: ,�., Are the motor vehicles used exclusively El AgriculturaVHorticultural El Educational L/.j'Religious ❑Charitable ❑Cemetery as indicated? rGive detailed description of use,including an explanation if multiple use classifications exist: I_ /ES 0 N ak"t 9 Vi S l + C./ ` V\e r s Ch(A kr c l S Ii No,give percentage of exempt use: �UNQY S c 4+€ S ' OM X- Co(174_ < hurck 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 also declare that I am duly authori .• •sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or emplo •-_It•=sed on t e,color,or national origin. sign i o �I To2 03 9 a- 1 here i g r F^ �I}FfJ Title f ` ` Date • CEI■L. MENTrn7REAE R RECOMMENDATION v'H• 77_ ©� E APPROVAL COMMENTS: • ❑DISAPPROVAL MAR 2 1 20t4 HALL AW(� COtF� • Signature of County Treasurer Date l wo kL4ND=laiBR 01"°CARD OF EQUALIZATION USE ONLY SA APPROVAL COMMENTS: ❑DISAPPROVAL thorized Signature Date Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 96-253-2006 Rev.8-22011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.