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en.--,- 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 /> Ap licant's Name ( Type of Ownership <br /> �"�`k-U10. .--._`: -Cin cA / i.l Rai 1+ f �:`r ��.C.i V��E.ull on roffi <br /> Street or Other Mailing Address J }� v� �-) County Corporation <br /> .L1 0. \/ti' . Z p'I 44 `l5�. P. G` !J oX J CC 1 i, i ❑Other(specify): <br /> City ( Slate Zip Code State Where Incorporated <br /> C--ravtc Esla.ind NF b8 L92 N r <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> , )erem LA RFCme�rS Pres 2Z114- ve .DIV15i0c•I 41 ME- lc,B ,'C' 3 <br /> Mcarr " rPi V. P. 7-1S St . A:i f-6.w c (`.-' ai_ h2i CoeVm, `l <br /> -, v`ts d _ , r r ere" i ,ScvD r . Z i2 S ;"CC_3 <br /> JutIe E:d.ca ( cre+u5 2147; i•i t Sart i C -T ICF (h�kt)- <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear Body Type Vehicle ID Number Date of Acquisition, <br /> B Newly Purchased <br /> )-loon e_ rnt/4. e. an ZwhetItnpen 3/2-8II ., <br /> i"4./er <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculiuralMorticultural ❑Educational ❑Religious ,'Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: i{ 9ES ❑NO <br /> FOr: 6 IVI1 Ct,i G, kVc.-t-clI1,1 5-c cc lc(iVt --Fr CDrv�J <br /> +J J 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 correcs.I <br /> also declare that lam 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 40� ,9 .l�r c �_ xr�c . D z� _`1211.3 <br /> here thorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> 's.✓.%-� 77-RECEIVE�"MENTS: e" ,a <br /> ❑DISAPPROVAL <br /> MAY 2 2013 ,`C" y°��riaa 3F-Z.� <br /> Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> nA.l COuN V <br /> TREASURERS OFFICE <br /> ❑APPROVAL GRAND ISLAND,NEBIMAL. C:I <br /> ❑DISAPPROVAL <br /> o 2 /J <br /> zed Signet <br /> Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />