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f i <br /> y� ` _ <br /> C Nebraska Department of I Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> vno�F;,v ass.-sse,e., •To be tiled with your county treasurer. A 57 <br /> •Read Instructions on reverse side. YJ <br /> • Applicant's Name <br /> �S�-.1 L <br /> Type of Ownership <br /> Street or Other Mailing Address ®CNonprofit n rata <br /> it s4i CIA �:r Rb^ t County Corporation <br /> i 0 1 dt <br /> City State Zip Code State Where Incorporated Omer(specify): <br /> 6- rtnatk 1sLik4 NE b%ao3 1E <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Sco- G" A"T"1 r^chLa <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make Model Year Registration Date or <br /> Body type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Foy S°,ILA A" 20 fH 44 DR - F.wa,,5.,,,) ,J,lvc StpzK3DCAES4)z-) 36 9/2S//oil <br /> Exempt Uses of Motor Vehicle: <br /> ❑Agricultural?lorticuflural ❑Educational 14 Religious 0 Charitable as dcate°d? vehicles used exclusively <br /> ❑Cemetery <br /> Give detailed description of use,including an explanation If multiple use classifications exist OYES 0 NO <br /> • 1 r p 6..-%-a}iU.^ o4 e seicAtA i✓�dt u i clot 13 If 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 ain 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 /, n t <br /> here �A6 rize Ripe--- <br /> /24. <br /> ! C /��j��, t1JSt��i A+0.gC i��1s�Z t� <br /> CE E Title Date <br /> ��// Rv UNT7TREAS�U�R,-ERYR_EnCO�M-MENDATION <br /> [APPROVAL COMMENTS. I "'Y"` �4,j ,i/ 'x-z7—o�Ioas <br /> OCT 1 8 2013 <br /> DISAPPROVAL <br /> TREMASSU RERRS S OFFICE p)J /;Z_ b-. <br /> //J-zer._/.3 <br /> GRANO ISLAND NE BRA'1 Signatu C <br /> nryTreasurer Date <br /> I FOR COUNTY BOARD OF EQUALIZATION USE ONLY I <br /> ❑APPROVAL COMMENTS: <br /> 0 DISAPPROVAL aj <br /> Authorized Signatu tr. Date / <br /> Nebraska Department of Revenue <br /> Authorized by Neb.Rev.StaL <br /> 96-253-2008 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 $§77-202(1)(c)and(d).and 663,185,and a0-$169 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />