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en-z— 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 /> ftpplicant's Name Type of Ownership <br /> MINISTERIO DIOS ESAMOR ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 423 W 3RD ST HALL <br /> ❑Other(specify); <br /> City Slate Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Ministe r Mouro Garc(a 152. . Hagge Ave.6irandjsfctnd AJE &gel <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Wehli,f•hmkv - - --- Model ----- aodyType- �-- '_-- Vehicle IDNUmber Dateot Acquisition, <br />• if Newly Purchased <br />• TOYOTA SIENNA 2007 VAN STDZK23C17S024267 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ,,,cccii�nnn <br /> ❑Agricultural/Horticultural ❑Educational Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: y1vES ❑NO <br /> Veb1ct2 is used by Mir\ Si-er +0 travel to Supervise. <br /> If No,give percentage of exempt use: <br /> urcllec of one rn nksfry M-kntskeri o Dias Es % <br /> flrnor 1n and o0-I" n+ -1--k,e s+oke Dc Nebraska .if <br /> lc also used -'o1' transpCf#Ct iof of favni ieS +cr andfrer1 <br /> ckut-r.14 a l/kcl 10 ofS4er ewes +key reed iv go. <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.) <br /> also declare Mat I am duly authonz;•to.•n this..emption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment•.• _• • race,cola.• national origin.gip <br /> sign ?e 'n, - A4j 1c.fer 1 1-23 -13 <br /> here Authorized Si• store/ Title Date <br /> �• FOR COUNTY TREASURER RECOMMENDATION 19 <br /> ' ED ,C�/ �e�p� ..,s7-..._, 'n`''7 2O.Z <br /> �PPROVAL COMM :NTS. <br /> ❑DISAPPROVAL DEC 2 2013 <br /> HALL COUNTY I'Signature of County Treasurer Date <br /> TRIn tSLAHDS O P, COUtITY BOARD OF EQUALIZATION USE ONLY <br /> 1/I APPROVAL COMMENTS: <br /> !❑DISAPPROVAL <br /> • e /—/A20 65L <br /> Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 603,189 <br /> 96-253-2006 Rev,8-2011 Supersedes 96853-2006 Rev.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />