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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 /> Appli is Name ' Type of Ownership <br /> J f,PA / <br /> /1 lS/r�.( /U /nit/ &Nonprofit <br /> Street or Ot er Mailing Address /1IR-1l-" a County Corporation <br /> -/ /!�� ,w,`t�n �y /- �' >n6• � � .165' <br /> '5 7 /I/ t/4/4p�lD EruV ! E, �`d' £SPf e s'F- 6S+c/ ❑Other(specify): <br /> City .. State -*Code State Where Incorporated <br /> Gr ) � Ain s / <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,Stale,Zip Code <br /> Maroc.rt 1?7AA:h6T-- A Xs5 sinG-0eo ifRiJ / C,&,* O r.5 N/= &8g. -C RJ Id csck� <br /> A9-T' <3R m a-n,Ac Ci. L/yA Ve Airy Pr kP , agog 7,'F Avc , fie e we f✓a 6f3c <br /> _Sl2GY¢-.C�n r`f /mil ojv. ?la Q WC P,IQ , r3o /v L GN .3t /74-v-e u?04- A)13'. - the 738 <br /> rr;e0_s✓e--e.r 1.44 _5'7-nkk rep Sec?. /s"-7 .tNzaa.LA_ rV 4 8't4 <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 /> .Aei/VC Cf±A go4_4 /785 /0,74 rAame- (3 135-67/m S'rx 17f 16aa6-,r7 12-/'i-/3 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaLHorticultural ❑Educational/� <br /> a01411 ❑Religious Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanatige if multiple use classifications exist: ,YES ❑NO <br /> ii C It ,:'jj eA -i 44.9r- " a If No,give percentage of exempt use: <br /> Y✓w0 be a tip, P,et -e 77*c 1+f 6r/FUiJ '�S.LR-N-0 <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 1 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 „ (� �.P ct pl7figa-C t2 /a-<9-i3 <br /> here I Authorized Sig re Tale Date <br /> *APPROVAL COUNTY TREASURER RECOMMENDATION <br /> *APPROVAL RECEIVED MMENt: - S ��- ��� <br /> //£❑DISAPPROVAI <br /> DEC 1 9 2013 _ �/�.� s� / °✓5� <br /> Sgnatu e W unty Treasurer Date <br /> HALL COUNTI OR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND NEBRQCKK�� <br /> APPROVAL tiUMM t 5: <br /> ❑DISAPPROVAL <br /> ji-C 411 - _ it i0?t o201gf. <br /> Authorized Signature ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§774020 gc)and(d),and 803,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />