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c7ZbILk <br /> ���--�- <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 /> Applicant's Name Type of Ownership <br /> GOOD SAMARITAN SOCIETY - WOOD RIVER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1401 EAST ST HALL 0 Other(specify): <br /> City State Zip Code State Where Incorporated <br /> WOOD RIVER NE 68883 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> See Attached. . . <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 /> DODGE-BRAUN 2014 WAGON 2C7WDGBGOER220305 <br /> Exempt Uses of Motor Vehicle: I-� Are the motor vehicles used exclusively <br /> og <br /> AgricutturallHorticultural 0 Educational Religious ❑Charitable 0 Cemetery as indicated? <br /> Give detailed description of use,Including an explanation If multiple use classifications exist: �YEREp (ED <br /> The general use of vehicles is to transport residents to If NO,givepercantegeofexemptuse: <br /> medical appointments, to and from hospital stays and WO 2 1 2014 <br /> recreational trips such as State Fair and parks. <br /> HALL COUNTY <br /> TREASURERS OFFICE- <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 popery does not discriminate <br /> in membership or employment based on race,color,or national origin. e ,Sig ■ <br /> Jere 3re-A0 <br /> `/ <br /> Title Date <br /> 1 FOR COUNTY TREASURER RECOMMENDATION /� <br /> PPROVAL COMMENTS: / /r ens /,l!SS 77- a�� <br /> • <br /> DISAPPROVAL <br /> i1 Signature �rTreasurer Date <br /> ,,,���/// FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> �Q APPROVAL COMMENTS: <br /> o DISAPPROVAL <br /> / 4 /uc - — '� • /C45f/g <br /> • Authorized Signature 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 /> 96253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />