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hit , ' <, .,J X0/3 <br /> • <br /> • -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 /> 0 Applicant's Name Type of Ownership <br /> MOSIAC <br /> ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2846 OLD FAIR RD HALL ❑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 /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,if necessary. <br /> Registration Date or <br /> I - - - Motor Vehicle Make - -- •odelYeer - Body Type- -- -- - -Vehicle ID Number Date of Acquisition, <br /> If Newly Purchased <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgricuituraVHorticulturai ❑Educational Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 24 0 N <br /> • _ If No,give percentage of exempt use: <br /> 0 ens—1 c} S<;I71 1c�IJ ;c JL1S <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 ,� _ _it L��} /-' r- �7i1 <br /> here homed Signatu f L Title f Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> I RECEIVED ,.A�� �/ <br /> IROVAL COMMENTS: .t4a"t tAt'a 4 SS 7" 7- 4cm. <br /> PPROVALNOV 1 9 2012 <br /> .02 / ' //`/‘ -•°102,HALL COUNTY <br /> TRFAS1RE RS OFFICE ti ounty Treasurer Date <br /> KA <br /> roll COUNTY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL a iff <br /> urhorizei ignature Dale <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§77-202(1)(c)and(dl.and 60-3,185,and 80-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />