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I p ifill <br /> •. = 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 /> itoApplicant's Name Type of Ownership <br /> MOSIAC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2846 OLD FAIR RD 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 Name,Address,City,State,Zip Code <br /> ctc A ) ) SLL\{tr <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Dale of Acquisition, <br /> if Newly Purchased <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational iff Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 'YES ❑NO <br /> • 'Yp .4-. ----o,•T C"y.`(9.,\CIA `\+/.q tJ tt"`'(S If No,give percentage of exempt use: <br /> % <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 � ILS, / -r ivlz/zut3 <br /> here IAu orizedSignature Title Date <br /> RECEIVEFOR CSUNTY TREASURER RECOMMENDATION <br /> �,yg,�,���` ti�� 77Qtj <br /> ZAPPROVA. COMM ENTS: /6,E— ", <br /> NOV I ' 2113 <br /> ❑DISAPPROVAL <br /> HALL COUNTY - X .Qt.tot- /_. j -./f <br /> TREASURERS OFFICE Signature GRAND ISLAND,NEBRASKA 9 tY Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> EA APPROVAL COMMENTS: <br />• ❑DISAPPROVAL <br />• <br /> • 7-,C6 /7t ?a:7 —� -2D/c4 <br /> IIIAuthorized Signature ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stal.§§77-202(1)Ict and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />