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FORM <br /> C Application for Qualifying 457 <br /> Nebraska from Motor Vehicle Taxes by fy 9 <br /> REVENUE Taxes s by u yourcountyonprof <br /> •To PROPERTY Name ASETESPPENT <br /> .lWd instructions on reverse site. Type Of Ownership <br /> Applicant's Name Nonprofit V a si i(.- County Corporation <br /> Street or Other Mating Address q Other(speedy}: <br /> `b 1 A -6-�"' ,�•� Zi Code State Where hxorporated <br /> City State <br /> Zip 3 0 <br /> 1 � 6 <br /> RS OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> RS DIRECTO <br /> IDE TIFY OFFICERS,, <br /> TNe Name.Address,City,State,Zip Code <br /> • <br /> OM <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,if necessary. Registration Date or <br /> Vehicle ID Number Date of Aequlsaion, <br /> Motor Vehicle Make Moddvear Body TYpa it Newly Purchased <br /> Toyk Sit-AA4‘ 2Dl '�I 4/)R- ch.+ ,•il...tc4yC- 1D, k3DC\ esw5+394 M 41 -at'Ii li <br /> Are the motor vehicles used exclusively' <br /> Exempt Uses of Motor Vehicle: Charitable ❑cemetery as indicated? I <br /> ❑Agricultural/Horticultural ❑Educational 0 Religious ❑ <br />• 3 f71yE3 �NO <br /> Give detailed description of use,including an explanation if multiple use classifications exist: KK--�t <br /> (� yy`` a If No.9�Percentage of exempt use: ,': <br /> 8S tIVSSt�a A()`sJi c{JS�S y <br /> • <br /> • <br /> • <br /> • <br /> Under penakies 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 owing theabove-listed property does not discriminate <br /> in membership or employment based on race,cola,or national origin. <br /> it <br /> sign Roc,A-es5 ti°vneat,- z�3faal4 <br /> �ze Tate Date II <br /> here , nizedsgna ♦ I <br /> RECE TREASURER RECOMMENDATION <br /> I <br /> godPPROVAL COMMENTS: it <br /> F E B 5 2014 r 1 ��L �1+�/ <br /> ❑DISAPPROVAL fi�[ A-O ClCpLt d <br /> HSURERSOF • Signature ofCountyT rer �� - (J 1LF <br /> TREASURERS OF �e <br /> . -.—• it••° t'nt';;7...• ;OARD OF EQUALIZATION USE ONLY <br /> it 1 APPROVAL COMMENTS: <br /> • <br /> ❑DISAPPROVAL - ��rl <br />• <br /> . earl 1 <br /> Dare <br /> Authorized Signature <br /> Authorized by Neb.Rev.S at.§577-202(1)(c)and(d).and 604,185,and 60-,189 <br /> Nebraska DepRarent 1I Revenue 253.2008 Rev.54009 <br /> 9F 253-200G Rev.&241 Supersedes PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />