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.. Application for Exemption FORM <br /> 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 /> plicant's Name Type of Ownership <br /> MID-NEBRASKA INDIVIDUAL SERVICES ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2536 CARLETON AVE 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 N�af'fme,Address,City,State,Zip Code <br /> CLo.irma.n SVavn \<k Po ac 04 Gi big Gel K)E 411014 <br /> Virc alairmaon Arnald &awn 3101 10 t Nelson E L 8`■ to 1 <br /> Sec./TreaIarcr R ilea Ce+o.V. zoti K 54 Orrcil A/?r G 884 Z <br /> G C 0 Diraati Coar+p bet( Alta f.) 0enutr Az.sf i n'1, Ng 6896 ! <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 /> SIC 4t1 eAss—k*saI l ; 51— <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 111 Agricultural/Horticultural ❑Educational ❑Religious E Charitable 111 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple(use classifications exist: ®YES ❑NO <br /> Tp fi-a,.ne poet aeUG(et Mm-44L1 II$sac`i° It No,give percentage of exempt use: <br /> �in A. ei€14- -l3 044 pr.:Wick BarthctS <br /> cor •emplats Mte_n'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 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 urea �,.. f1D il-rec` `�i+ r1.�vt- 61`1c+i13 <br />• <br /> here 11 Authorized Signature Title Date <br /> FOR COUNTY <br /> TREASURER RECOMMENDATION <br /> RECEIVE�MMENT, SU2 ./52-8--1--� �',y`-q <br /> 77 yc <br /> APPROVAL <br /> ❑DISAPPROVAL NOV 1 8 2013 u �c t/ <br /> I'Signature of County Treasurer Date <br /> TREA <br /> GRAND[CLAW/.NEB NTY BOARD OF EQUALIZATION USE ONLY <br /> PPROVAL COMMENTS: <br />• <br /> ❑DISAPPROVAL <br /> IP i m z�.—� � /- /4a0P I <br /> it Authorized Signature Date <br /> n 185 and 60-3189 <br /> Authorized by Nolo.Rev.Slat. 77-202(1)(0 antl tl,and 60.3, <br /> 96253-2 Department Rev.8- 11 Supersedes y 44 (l <br /> 96253-2006 Rev.8-2011 Supersatles 96-253.2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />