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*' Application for Exemption <br /> FORM 1 <br /> Nebraska Department from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be flied with your county treasurer- <br /> side. <br /> C n reverse•gpplirshi <br /> G instructions 0 Ownership REVENUE .peed T of <br /> 17G r 6 Type Pplicant's Name 1.9ENi <br /> IoName Nonprofit I'� <br /> D r n. County Corporation <br /> Street or Other Mailing Address 14'r II ❑Other(specify': <br /> .��410 1�' �; r s`t State Zip Code State Where Incorporated <br /> City C� 6gev3 i <br /> & l-u nd <br /> IDE TIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Narne,Address,City,State,Zip Code <br /> • ii <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. - <br /> Registration Date or <br /> Vehicle ID Number Date of hafe d <br /> Motor Vehicle Make Model Year Body Type it Newly Purc Purchased <br /> Toyph 5;tee,+.q 2011 q nit- c•w+ ,.w..-tcbvx. STDZk3 pc_\ asi.5qui v /2bH 1 <br /> Are the motor vehicles used exclusively�i <br /> Exempt Uses of Motor Vehicle: Cemetery as indicated? <br /> ❑Agricultural/Horticultural ❑Educational m <br /> Religious ❑Charitable ❑ ry <br /> YES ❑NO <br /> Give detailed description of use,including an explanation if multiple use classifications exist: <br /> a JS� If No,give percentage of exempt use: <br /> • 1 r°^SF9^1 ��ar rnc oVSvtlut nd J, 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,r and cwdmina.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed properly <br /> in membership or employment based on race,color,or national origin. <br /> g PI tCSS IIAAA&eY ^.,�3% I4 <br /> sign \ /J >s Date <br /> here orized Sign 1 Title i 1 <br /> I RECEIVE.V TREASURER RECOMMENDATION <br /> [APPROVAL COMMENTS: `�� <br /> ❑DISAPPROVAL f�� ,,� .�� <br /> F�� 5 2014 i�• <br /> SiggnLaC�r��'�n r Ns.�s D <br /> HALL COUNTY ,Signature of County Treastrer (Uf <br /> TREASURERS OFF! <br /> GPn u IbLANO OARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • iiraart Mi trr: 1(19 <br /> • Authorized Signature Date <br /> Authorized by Nee.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,183,and 60.31.189 <br /> Nebraska Department Rev.8-2011 Supersedes ss2s3-loos Rio+.a-zon super=ease s6-253-2006 Rev.5-2o09 PLEASE RETAIN A COPY FOR YOUR RECORDS, <br />