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ink--` Department De Application for Exemption FORM
<br /> RE�/ENVE 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 --}}�� j /` �/� + / Type of Ownership
<br /> • Mfeloka.sKG D'siRtck COuAc.\ 4 -thy. Assew (its O4 Goa Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> i 6b3 W. ;.48 Si Po ,ox labs N c,11 ❑Other(specify):
<br /> City State Zip Code Stale Where Incorporated
<br /> Co Rated 2s■c ,,d NI t 408 RC N c
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,State,Zip Code
<br /> St-Vales{cnda-..t Rnbcx} Wine 307 E. 54" si,as- PI. Ke-&at1tey NE &%C47
<br /> Asst-r tstpf,e;A+cwee ....4 Gr.„_,e_y Nov t 5-1 09 T;mbcAR , df(AK d e be. Nip; II,o., NE 681(3
<br /> 5ccas,+ y f-tia._sukCA 7e,a2.l BROWN fo'fcO hc.(5lc�e c 't.ncolA NE 4„g 5-09.
<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 /> if Newly Purchased
<br /> Tdirk- S;GO G. Poly FWtb 2 P�ssev.5en 5TOt<1<3 DCSE55a G/ab/I '-1
<br /> 43O
<br /> Exempt Uses of Motor Vehicle: XReligious the motor vehicles used exclusively
<br /> ❑Agricultural/Horticultural El Educational IXI Religious ❑Charitable ❑Cemetery as indicated?
<br /> Give detailed description of use,including an explanation if multiple use classifications exist: pCIYES ❑NO
<br /> ' n r S 1J e i c+[l Y W u tit_ USC A it g'‘-c- ('•"S4T-'lc"k C e• •"- 4° cc. 2 If No,give percentage of exempt use:
<br /> illfl\OP t tkq,A OIL) ckt,AC-L.c6 i.,. IVeI,“s KA 6. 44 Retake_ t4t4
<br /> as-0 c&cdc ∎o[cd Ns-I-cats a� rn11,' sk&c . T} kj, U At CD
<br /> 13C uStd 40 (COLA Inc+K OVfL- 7;c42- c - Cv{• *S, C(n do S
<br /> C6nuent;o'v\c , SCw∎tv\c..n-s , cl-c -
<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.=- .on race,color,or national origin. 1 `
<br /> sign.. r __- � lv��a,. ,� (0 .i �=l�-
<br /> here Authorized Signature ` Title Date
<br /> c"O^nUNTY TREASURER RECOMMENDATION
<br /> PPROVAL REhIVbD ,✓4C:05. �o�
<br /> COMM:NTS: /�'w
<br /> ❑DISAPPRO/AL OCT 1 O 2014
<br /> ��2CPi/Z /�0-acv -'7'
<br /> HALL COUNTY •Signature Treasurer Date
<br /> TRencuncnc or
<br /> �
<br /> " GRAND ISLAND,NEB COINTY BOARD OF EQUALIZATION USE ONLY
<br /> VA,IaPPROVAL COMMENTS:
<br /> ❑ DISAPPROVAL
<br /> �c .'� --,
<br /> It Authorized Signature aat-
<br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.H77-202(1)(0 end(di.end 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.
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