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;DP/ <br /> •�- Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> G •To be filed with your county treasurer. <br /> • •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> • CENTRAL NEBRASKA HUMANE SOCIETY ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1312 SKY PARK RD HALL ❑Other(specify): <br /> City Stale Zip Code Slate Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> 7' Adrress,City,S1= 5,Zip Code /i <br /> SRNS/:s t .1.r A11W�.o ) . 'c o• rr EMIGiltall <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> .__ Motor Vehicle Make - ModetYSar _. eodyTYpe- - _Vehicle ID Number Date of Acquisition,Newly Purchased <br /> .a . QQ --- --at-0 1 _.- pi__ y�L+-._ _ __ t i-.2_, f <br /> ,„ _ x•r- a .-r ` C�'I—an ' ( Cie 4925CARilli9/12- <br /> Dud e. Ca Van ao0l Van a6-74s11XDIKS1rj2c18' <br /> �reslf 'f7A1tC. AoI)-- `f%rcl0Secl Iran I-. PASSOR ``tt921 - . <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational III Religious Religious (N Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: , YES ❑NO <br /> Cr iL <br /> y 14---/17 Cr .mil-t_- If No,give percentage of exempt use: <br /> � CEnct . fact <br /> `-t'� r(X-17.5. °,,,c-'el.��`S-rc rC4 ['v- 1a=i J L{ L Ii c - r <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 coned.I <br /> also declare that lam 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-, `] . _Are p 77-4-0( gxccu-I-tYa Direr-or /i/ctilr, 2flf3 <br /> her Air "ad Signature Title Date <br /> FAP COUNTY TREASURER RECOMMENDATION <br /> RECEIV . �--"„ �D J ,/q'S• -, , <br /> APPROVAL COMMENTS <br /> ❑DISAPPROVAL NOV 8 2013 , <br /> iLt- P-Orge 4c a..k.— /-.3-iy <br /> HALL COUNTY r Signature of County Treasurer Date <br /> GRAND I a• k a{c,`,°r_NTY 3OARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> B mc 7- ) /—/ L41 <br /> • 'Authorized Signature _.__. Date <br /> Nebraska Department Of Revenue Aulhodred by Neb.Rev.Slat.95 77-202(1)(c)and(d),and 60.3.185,and 603.189 <br /> 96.253-2008 Rev.8-2011 Supersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />