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Rif <br /> 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 />• <br /> Ilicant's Name Type of Ownership <br /> NORTHRIDGE ASSEMBLY OF GOD ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3025 INDEPENDENCE AVE HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title 'Name,Address,City,State,Zip Code <br /> CaPoe$' Paect•6e,"Vf MAP-IL bBER9r)8'3 SItr.EwooDkat)GRt4 BIM)/'4 68803 <br /> h Seat1'API in f'£. 1-1A0.,F2 1615 S RRUwI sJ 4 Gp,wbSste✓% pt tarn <br /> h TILWARAa, ,ktkRt stA4NDf l 1so 761742E ROADS AuAeM, NE 6881 S <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> — _..- — - -. -- - - - Registration Date or - <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Fe11P <br /> 200$' kCONOLIWE wA6& I BZ,Stni <br /> ron-D 1195 Cleve WA600 c3sa I Farsa1 NosH$19906 <br /> CA-ASSit 1419$ Meta c aSF.D `PItAiL $- I01.0PAEE21s10e2o't5 <br /> Exempt Uses of Motor Vehicle: „--,,`` Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural El Educational "religious El Charitable ❑Cemetery as indicated? <br />• Give detailed description of use,including an explanation it multiple use classifications exist: <br /> ES ❑NO <br /> p1.44V . rX r *s <br /> Cars kl kka ?elk Anted tutille, <br /> If No,give percentage of exempt use: <br /> Lb4"w• <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and belief,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br />• <br /> in membership or employment based on race,color,or national origin. 1 .� <br />• sign G� 0( O,, z L Pea,` /Pe$ick 74_11 3 here I Authorized Signature Title <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVED COMMENTS: iZ� 'Y'” Ay �9`�-` ...-7....-, <br /> ❑DISAPPROVAL DEC 5 2013 � <br /> °It� /<— -'.-- (-5.` <br /> HAI t COI MTV F Sie of C my Treasurer Date <br /> CR'TREASURERS DI LAND, OFFICEIWR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> kAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 41 E2 /if <br /> • Authorized Signature ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d).and 60-3,195,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 />