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.—e- 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 /> none •Read instructions on reverse side. <br /> Applicant's Name AA'' cc {� r //�� `,r , �j Type of Ownership <br /> Mt 4'IJ E 1210 J�oc 'G. c Act ol�- Jonprolit <br /> Street or Other Mailing Address County Corporation <br /> Lf 2 3 �• !, 5 � r?�J 4_S 6nCL 14 Pt- LLB <br /> 0 Other(specify): <br /> City State ( Coda / Slate Whe�IrlCOietl <br /> IDENTIFY OFFICERS,DIREyLC�TO�RS,OR PARTNERS GOOF THE NONPROFIT ORGANIZATION <br /> Title . ) 5 l 7)12. Name,Address,City.Stale,Z n Code <br /> ,'O C7 <br /> A/14u , nQGY4- l 5 9? blow e 4" &r a'CGt'o/ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number Date of Acquisition, <br /> H Newly Purchased <br /> yn fOTi4ci UH4C°� 9,Db7 C br t/4L) 57-D 2t 23r•(7Sn7zoZ? <br /> Exempt Uses of Motor Vehicle: ,..,Rel Are the motor vehicles used exclusively <br /> El Agricultural/Horticultural 0 Educational L(.j' igious 0 Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ffS El NO <br /> u5.. V€ Si + t4h2rs CkuV'ck <br /> (( (( If No,give percentage of exempt use: <br /> 6TV\C)6 �TCCTeS' gOA.1/2.- kpCa. c kurch. <br /> Under penalties of law,i declare that)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 author .- .sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or empl t,- i•on : -,color,or national origin. <br /> sign p �i PST-02, o - 2a- 13 <br /> here 'Authoriz Sig re Title Date <br /> ' RECEIVED" NIrTREASU RECOMMENDATION ,$C' rr <br /> E APPROVAL COMMENTS: A'� N9'H• 77- <br /> D DISAPPROVAL MAR 2 1 2013 <br /> HALL COUNTY <br /> RS It Signature of County Treasurer Date <br /> -'ARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> .••••• . 2 <br /> thorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat§b 77-202(1)(c)and Id),and 60-3,185.and 60-3.189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />