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Nebraska Dentot Application for Exemption FORM REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •Read Instructions on reverse side. Applicant's Name Type of Ownership•• $ L 1, 1►. •. a — as ;ss'. • l tN Nonprofit Street or Other Mailing Address County Corporation RD. 1lnx 13b1 L4cU 1 ❑Other(specify): bity State Zip Code Stale Where Incorporated rb-nri„ Iorv-9 NE 62862 NE IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code tt s .. '.. • . . '. • ' 2 ' • ••. . 5_ ... • •• • E .. . r • • • • : • . .. .• _. . .. N. .. . • • .. • a • • W ' • . *ALAI La r•_ - s_.• h. ► DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,If necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, It Newly Purchased PaIllmark 724,le r ?nikJ tTF 5X2UwT3 5`156B2,-122EuSsfl iw 3-31-2D14 Fnrd 199'1 Chu5sistOt•hwii31wrn1FDLFf-11F?VEDp333•11 3-I7-MN Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively A riculturaNiorticultural Educational Religious as indicated? ❑ g ® ❑ g El ❑Cemetery Give detailed description of use,Including an explanation if multiple use classifications exist: ig YES El NO c: tJ%ed as+ ea pile os,F ne +o pvoii' If No,give percentage of exempt use: • j .t`1�` �'arVe..ne-:'`\C� . (yy� /I .1y yyKy, /1�.�J`� /� �11y . �70.IC,- cisEi , a5 1 ' vb116... aC 1 0i ,i I�1..1.1\c�• Wl�, `KJ *o eke 5coO'4InV ac'4 +e Oafl0s CoMMundtES Under penalties of law,I declare that I have examined this triplication and that it is,to the best of my knowledge and belief,true,complete,and correct.I also declare that I am duly authorized to si iNS�e • wn pplication,and that the organization owning the above-listed property does not discriminate in membership�or e(m�oymeent as race,color,' ;ati nal origin. sign 7�Jau /� •�rr+t!// c�rflu-E. Exam i,v-e .3-.31—W here I Authorized Signature Title Date FOR COUNTY TREASURER RECOMMENDATION CL]APPF OVAL RECEIVED CDMMENTS: " ��'� 111- r 77-& 2.- ❑DISA'PROVAL APR R i 2014 7-0-: . Signaturie County Treasurer Data NALLCOUN7Y FOk COUNTY BOARD OF EQUALIZATION USE ONLY TREASLAED, EBRf S� GRAND ISLAND,NEBRASKA XAPPROVAL COMMENTS: ❑DISAPPROVAL l�}•t �/L� � 0.Authorized Signature 'Date /11/01Uy 15L Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185.and 6133,189 96-253-2006 Rev.8-2011 Supersedes 913253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.