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Nebraska 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 /> plicant's Name Type of Ownership <br /> CENTRAL NEBRASKA CHILD ADVOCACY CENTER [g Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 721 W KOENIG ST PO BOX 844 HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> P' "Ti :Lein- . _ \\. , 2- - ...n i I ic.cic NE . .','cc' <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> I_ _ _ _ Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number if Newly Purchase <br /> if Newly Purchased <br /> ,- d e. BDC.iiC I . L-1, s, 1 54,, <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural 21Educational El Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 'YES Er NO <br /> This tie LIIC(e. 1 Lttht4- :f4. TI&-V � to- €LQV-`vi co,k titV-3 If No,give percentage of exempt use: <br /> cl-I-A3 Gretna rakVtd IC QUevi A and- part p,er,l-e, % <br /> in NOT ✓noel .vt,yst pcevt(le advacow11 2wd -f-fq.vltit I-esardtvs <br /> 5ef✓" ldr' ctttt1d otc_t—�s o'� Q6u8e_ evta 5G.kt2k:: 4ssavl-; <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 /> in membership or employment based on race,color,or national origin. <br /> sign f G' 4E�, - Caw % arry /1-' VI 3 <br /> here IAuthoriz ture Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> t �• d J , `� <br /> 2/APPROVAL RECEIVEDDOMME JTS: 6ny , . / . <br /> ❑ DISAPPROVAL <br /> DEC 1 6 2013 �, � ��..t= �,�y <br /> Signature of County Treasurer Date <br /> HALL COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASuRtnS utmiCE <br /> GRAND ISLANDS NEBRASKA <br /> 1,APPROVAL - COMMENTS: <br /> ❑DISAPPROVAL <br /> ) Ul <br /> • it Authorized nature i— 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 />