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= . Application for Exemption FORM <br /> I rev'Nebraska Department of <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 /> Ap•licant's Name �1l Type of Ownership <br /> rJ�W• <br /> S. �• #a 21. — I. 1,...•- • .-_I_ -_k tNonprofit <br /> eet or Other Mailing Address l� 1%10.3 County Corporation <br /> 1%04 S �'L• P 0 3O)( 1 `u k 1` ❑Other(specify): <br /> City/1 / State Zip Code State Where Incorporated <br /> Grr Sg1arek. __. Ina Eeq M a_. <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Pat Aterptrl'1 r) <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> 1 Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> T ..... . lb,...... -- n - ir=t ' 9= .. • I <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural Reiclucational El Religious Q Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: , S LINO <br /> LLSC d Crc' T1aL1A_1 �/ �1 I�doc'a ri or), i- yLk— <br /> (�b If No,give percentage of exempt use: <br /> 1.StAePort. ow-- dkgc t\:1-y .\:::.ro3KRwc-s. . <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 authoriz sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment b ed race, Ior,or nation rgin. <br /> sign / i od-i-ra tl .5--02/- /1 <br /> here I Autho ized Signature Title Date <br /> OR COUNTY TREASURER RECOMMENDATION <br /> T APPROVAL <br /> RECEIVED COMMENTS: 1re./4214-414-•4• 77- ge `2" <br /> ❑ DISAPPF OVAL MAY 2 1 20t4 <br /> " � at L _o-t,7,-P-/-7, <br /> NAI lI•M HJTY Signatur o ty Treasurer Date <br /> 'TREASURERS OFFICR FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> L O4^ND ISLAND,NEBfASKl1 <br /> K I APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 4 m' °Q f WW/4 . <br /> Authorized Signature Da <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 />