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• <br /> Nebraska Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •To be tiled with 457 <br /> acooi=;,,v tses�sr.�s,r your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name <br /> 1 `D�w 1 (-- <br /> Type of Ownership <br /> Street or,Other Mailing Address Nonprofit <br /> County� 4 C % a 8 old Rc, County County Corporation <br /> I i■ <br /> City Zip Code State Where Incorporated ❑Other(specify): <br /> 6- ro .r•d 1s Lt,4 NE 6$803 1J <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Lp Code <br /> SL, c'M- c chLA <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make Model Year B Registration DHs or <br /> ody pe Vehicle ID Number Date of Acquisition, <br /> 1 O D�A S sx w q to � From If Natty Purchased <br /> y '-iDR ^ w�.4An,c SibzKIne.9esylz-i36 'I/iS/2o13 <br /> • <br /> - <br /> _ <br /> Exempt Uses of Motor Vehicle: - - <br /> Are the motor vehicles used exclusively <br /> ❑AsricumaalMOrlieabaral ❑Educational Religious ❑Charitable 0 cemetery as indicated? <br /> Give detailed description of use,Including an elplarKtloo if mullglie use elassiilwtion1s exist OYES ❑NO <br /> 1 rww-S p a.-�.q o ea4 so3o� i plat'u i c\a'.LS <br /> If Na 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 am duly authorized to sign this exemption application,and that the organization owning the above-listed properly does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign <br /> here /� tri t,�s Baal tr lofts/z�t3 <br /> ri�f+ s �a Date <br /> i I nut UNTITREASURER RECOMMENDATION <br /> 3 PPROVAL COMMENTS: "7, i 44 #? `;oa. <br /> OCT 1 8 2013 <br /> ❑DISAPPROVAL E COUNTY �O�I /' ' j <br /> /O-Off'-/3 TREU ER OFFICE <br /> GRAND ISLAND,NEBRASKA signetu y <br /> measurer <br /> Date <br /> ,.�/ FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> L�APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> alb <br /> c � Ca,f. r_��! �V as dU/� <br /> -Authorized Signatu Sr Date <br /> Nebraska Department of Revenue <br /> 96-253-2006 Rex 8-2011 Supersedes 96-253-2006 Rev.5-20bg Authorized 'R8�'. 99 Tf' Itlfc)and M.and 803,185.and 603,188 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />