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men.7---z__, Application for Exemption FORM <br /> .Nebseelo -pertment 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 /> Applicant's Name 1 _` S y,l Type of Ownership <br /> GCICALc]tI1 �A.U- 1<-s Q� CJr� !�\ntaSc _,r\C. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> t%n4 ¶S St. Po goX kZLoT K k I ❑Other(specify): <br /> City States Zip Code State Where Incorporated <br /> p <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> The Name,Address,City,State,Zip Code <br /> Pe°c M4pched <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> *Attach an additional sheet,if necessary. ' <br /> Registration Date or <br /> Motor Vehicle Make Model Year Bodyrype Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Lk-61111 a a a I 55.i -tnisler 1113.vLSai MSPLAa 08 -1- tZ-tai <br /> U+altl-y soot 5.,rtria -30.0., r 1ayvgas3ta9.o92-lot n-t-t- 13 <br /> u+;I. aunt '�rci'-4tn tlr I a' C3L r.f 98oc -1-n-t3 <br /> Exempt Uses ofMotor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural kg Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description off use,including an explanation,i1 multiple use classifications exist: MMES ❑NO <br /> �+13� Rex t4 1Aq'C ok tt.. \- N. cg cjcra4ricns If No,give percentage of exempt use: <br /> J J <br /> 51Mppert Ota_r a Sabi I;41 Qroyra.rvas . <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 7 l U1 d Ifer 0-'1-15 <br /> here Authorized Signe P_ - Title Date <br /> ,/_ <br /> ca; COUNTY TREASURER RECOMMENDATION <br /> I ' <br /> ZAPPROVA CO ENTS: "ge /- yd-s 77-.Q0.2.., <br /> ❑DISAPP-a AL JUL 1 8 <br /> Lp 7/9-.7o,y <br /> TREASURERS •COUNTY Signature of unty Treasurer Date <br /> 7 [t s UNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> Ia.,' /,..- ./. y/,/!_ / - . r <br /> authorized ignature (r /'ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3.165.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 />