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v Application for Exemption FORM <br /> .s'Nebr ska Depa ment of <br /> REV_ ENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations ? <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applic. is Name II ✓� T .e 0f,Ownership <br /> eCk+ ? 10.1 ns I 1 1 0 • "Qr' " • Ol- A I � A I onprofit <br /> Street or Other Mailing Address (� County <br /> y� C u Corporation <br /> O • IS b)( 5)��) H R-L1— ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> G ro.nd t3tQr d, 1,„\ E 40 8g0 - Kgnsas <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title • Name,Address,City,State,Zip Code <br /> r...' as •�Cr� ,: aesa . 1�. Y1C. flob ZVII : *mc\ ie.,t ' \ b031 • <br /> E .• ► vua5 omm; ISIBEENIIMinfl12.Bri .. . .: <br /> ..:_, a Ok- < It.a A:_ .m ai:Lla►! a fY La Mirkt- M MeJ► • ♦ • ► •• <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 /> a- )nCI o` 2-o09 eK-V-EX J141-RE48519 coo9oLo <br /> I <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> El Agricultural/Horticultural ❑Educational (g(Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: c:\-- <br /> 1 YES ❑NO <br /> 10 +rav e\ \-0 ckna ro m Or) €e.�i nqs I n M2 6146 <br /> �' If No,give percentage of exempt use: <br /> QS we-1,k Qs hose 11-gls, z l\om v1s 1 kts <br /> rp vs.--rc c* cSu-p.er; n 1-Quinn*- ±ro\Ve,ks ctcCQSS#kQ <br /> 5.k--a1-e. 1-o (SupeeVi se-Ta5-i-ors t,' lisouru n3 eivArc_V15 <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 l 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. l <br /> sign D peein\enjfrkl07-S`/1/ <br /> /t fs� r�c <br /> here rmrzed Signature V a Title Date <br /> T 1 mitt YTREASURER RECOMMENDATION <br /> VAPPROVAL RECEIVEPMMEN,D: <br /> r I <br /> ❑DISAPPROVAL F E B 7 2014 <br /> / a _ i. C..._ .Is _._ r7j2.019 <br /> NA LCOUNTY Signature of County Treasur- ate <br /> GRAND Ii REDS Q SLAND.NSSUt1NT4 BOARD OF EQUALIZATION USE ONLY <br /> f]APPROVAL COMMENTS: <br /> • <br /> ❑ DISAPPROVAL <br /> / / <br /> Authorized Sig ature Date <br /> Nebraska Department of Revenue - Authorized by Neb.Rev.Slat.§§77.202(1)(c)and(d),and 60-3,185,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 />