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!?4i) , ' c65•SZSt„) EXt IOW <br /> Mir° --Z-- Application for Exemption FORM <br /> ' Nebraska Depansdant 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 /> OA{pplicantts Name I� I '/ -{- Type of Ownership <br /> • /141 Plait f(tile, {or be It.i.®e/ ry eel41 Cate Se-c Ulf_Pj -FN6 Nonprofit <br /> Street or Otherr{Mailing Address Couunty Corporation <br /> GIS Alec•r1 Elko •ro 11 ❑Other(specify): <br /> City Slate Code State Where Incorporated <br /> 61\24 j Is I<a) Ale QUO/ <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> CEO <br /> &,;e eelsi trds <br /> Eke 4e&vsrt $2 Ake Macedi 4103 /any£i(/sew Kra (On,A ry Alf 6 y7 <br /> S eQ also 19t1-1 ¶JL-e J <br /> DESCRIPTION OFTHE 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 N Purchased <br /> mite 0001 'dot mmtlkr aagGP44351 IRa1 ,'icIIf 6� iN <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural 111 Educational ❑Religious 0 Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES ❑NO <br /> ire ar00..4:Ai Coo 3Uoe/ S as/itom pro5ems/ ecun3/clss !rw43•1/405 <br /> If No,give percentage of exempt use: <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. a�/t I ( bale iI4l'{tcf.e <br /> -6€/At Tr.4 SC4If Id pis my&nt'ar-t.. aos,:t1 set van INL <br /> sign L _ zyP&ed :± <br /> here ' ih• '.=d Signature ate- Title Date <br /> FOR COUNTYTREAASSUURRER RECOMMENDATION <br /> APPROVAL RECEIVED MtNi 5: Site r Al: 4 7'_-7°et" <br /> ❑DISAPPROVAL <br /> 01,f l O —R 7/� <br /> AUG V 2014 �Signatur o C ntyT�urer Date <br /> FOR COON BOARD OF EQUALIZATION USE ONLY <br /> 1 <br /> TREASURERS COMM <br /> yCl APPROVAL - D ISLAND.N <br /> !!!�❑11 DISAPPROVAL <br /> Cczc2 - ///9al4t <br /> /Authorized Signature Dale <br /> •Nebraska Department of Revenue Authorized by Neb.R .Stat.§§77-202(1)(e)and(d),ana 60-3,185.and 60.3,169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />