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Nebraska Department at <br /> Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be flied with your county treasurer. <br /> Gamin •Read instructions on reverse side. <br /> App' inns Name e .{/�� (/� /� i� I `/.' Type of Ownership <br /> • L i S I. ) f I t 1 } ! K1"r A Nonprofit <br /> Street Otaer Maill A.ddre s Gou y Corporation <br /> x ID i RI },k-i z b Pet. PCB i3 DX 5 1 ;,5 7-1 r�i I ❑Other(specify): <br /> C }i(C�is 1-Ji�I Ck N b .p Code Slate Where Incorporated <br /> - 1/2 'Fo <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Na Address,City, i te,Zip e <br /> (*oat CAI Cur A�'1 et-�, IYyL l -4 't�aih .Malici e=.tor . eii U� bP)ha <br /> vice 0Cinir Z,�a.i+ • &i✓c.Lhiurn .3[ L-f il) g c,t, iZ N6 bcst"o) i <br /> -ite 6,S ak`a- dim Kore n<7 l 1 l`3 i 16- y-ctinJe. ..a s iv E- && 3O( <br /> sect retatfj SOry- Vle- lnnW (40L iU ( 5*' St. (" t1 E. P;Ls�;l <br /> J <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 /> }k0mei7,ar;e Ira i }cr. aooi Flat of0 ILODOC1IO laUNt.• <br /> IA 1 uXh - ,-∎n e 1 t 1€, ?t l fli rc r Tri i le r I lA el Cs 3 i o ridOC l+i1' b, <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious I�Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation ii multiple use classifications exist: .�; DYES ❑NO <br /> ails y , l( ,,,n + - vi i )oa. 1 1 i f fC l� (1.4, t r!` 7 If No,give percentage of exempt use: <br /> Iiii 01/4-124-,tik'Y-/`il-L to AA kth1' (Ai t,Rer�( )- W ) i ��e <br /> /.ttv a' tbi44 kat/, o. to of Al ea(k 4 <br /> I 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 m rsh' pr employment ba d on race,color,or national origin. <br /> sign f 26/_,a ,Aa/l./I B'a1 �4-tOit of Eke. OJ( )/al 14/14- <br /> here Authorized Signature Title Date <br /> RECEIVED FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL - COMM:NTS: '` "" � <br /> Y`� ,ac -t-Ai. •°5. 7 - 20a...) <br /> JAN 242013 . <br /> ❑DISAPPROVAL <br /> MALL COUNTY v a c—t-6L.'-• /- cQy i'� <br /> TREASURERS OFFICE /Signature of County Treasurer Date <br /> _ (ARAN)ICI AN ,NFRRACK, <br /> FOR CaU■TY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑ DISAPPROVAL <br /> • It Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(6),end 80-3,185,and 603,189 <br /> 95253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />