Laserfiche WebLink
'`'' <br /> Ne�braskaDep�enmeentof Application for Exemption FORM <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 /> illApplicant's Name Type of Ownership <br /> TEHAMA SHRINE/CENTRAL NEBRASKA SHRINE CLUB E Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 5575 S ENGLEMAN RD 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,Stale,Zip Code <br /> PRES WAYNE WREHM 2777 N BROADWELL AVE GRAND ISLAND NE 68803 <br /> TREASURER WILLIAM CARSON 5575 S ENGLEMAN RD GRAND ISLAND NE 68803 <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 /> It Newly Purchased <br /> DODGE RAM 2002 PICKUP 1D7HA18NX2S571594 <br /> SNBD 2010 TRAILER 5NHUSNZ23AN069814 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> [1]Agricultural/Horticultural ❑Educational ❑Religious E Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> USED TO PULL TRAILER WITH GO KARTS TO PARADES TO PROMOTE SHRINERS No,give percentage of exempt use: <br /> If.HOSPITALS FOR CHILDREN. <br /> q <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 /rte 4 tip . l (2 3 <br /> here I Authorized Signe Title Date <br /> RECEIVED,... 'TREAASURER RECOMMENDATION <br /> APPROVAL COMMENTS <br /> ❑DISAPPROVAL DEC 1 7 20 13 ,c <br /> % i c ao� !— --V. <br /> J1uRFRSrOF 'Signature of County Treasurer Date <br /> `ISLAND,N1 f T�'...Amer OARD OF EQUALIZATION USE ONLY <br /> 08,APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • / At ` L CL' /j4 -070/1/ <br /> /Authorized Signature �--- Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 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. <br />