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•net—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 /> cari •Read instructions on reverse side. <br /> Applicant's Name �+ 1 Q Type of Ownership <br />• <br /> 1}i d — Ner.rwsltc.. -LndirltA0,0-k 5et-rjcaS 4Nonprofit <br /> Street or Other Mailing Address County �� 4.`, Corporation <br /> 2.5 3 6 Ce. 4a kor, Q V C. ` ❑Other(specify):State Zip Code - ' State Where Incorporated <br /> Gra."1 lslc-.,nL N E G. $ eo3 N1< <br /> , <br /> IDENTIFY OFFICERS, <br /> DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> CAN et_xrman. Tvo-.. Klr.rn Po Bx 13 (c;660 . ALE L ?rag <br /> V. e_ u . . I: , ;o GfA k " o, . t 8 ' 4 ( <br /> ,Sec. Trewst..rcr Allen Ce wk zon K S •r - NE h 88L 1 <br /> e 0 I . , a .. , bell _ t(. N _, der 41 6 Vlof <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year eodyType • - Vehicle ID Number Date of Acouisition, <br /> it Newly Purchased <br /> C.111'9 sl,c. r— :LO IA 44r14Tdur:nq T •gRc•11se6GR3512]1 4-m-i3 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaLHorticultural ❑Educational ❑Religious VI Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation ft multiple use classifications exist: YES ❑NO <br /> To co v s P oc't A .V el o P m e h e".11) d 5 S to e d If No,give percentage of exempt use: <br /> li ri A. V. -1 <br /> A c•-05 0 - A d S provir.. SorVict <br /> rOr e-•• e(o, main+. <br /> Under penalties of law,I declare that I have examined this application and that it's,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. q y� p _ <br /> sign , v 4-UtA LA S•t/VV,10.g vy-,0_.✓, - I'1-rf a V( rt c4 to) rl J/: <br /> here Authorized Signature \ Title Date <br /> �J FOR COUNTY TREASURER RECOMMENDATION <br /> 'r^'�/ <br /> APPROVAL COMMENTS: ' /'�-ND -44,44' 77- ` R_'° <br /> ❑DISAPPROVAL VCV'.183N'ONVISi ONV J <br /> 301 A1NSf100 TIVNSV32LL C1O/ CST°°_ '.. de ?4'-/,3 <br /> • Signature of County Treasurer Date <br /> EIGZ 0 PI 4 7 s1hI QR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL ®3A13O3H , <br /> uthorized ignature S7 Dale <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stal.§§77-202(1)(c)and(e),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 />