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?e�— 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 1N,am-e -I--T (� ¢ ('-/1 , Type of Ownership <br /> Uvtr LEI�L7, J inn 1IS [ nti n01 I —�E1V C 1Or L 'S O Arne.rICO_ Cgl Nonprofit <br /> Street or Other Mailing Address I County 1- t Corporation <br /> P D. 1Jnt 13L6I 4ai I ❑Other(specify): <br /> pity State Zip Code State Where Incorporated <br /> brand_Zslanril NE 6281)2 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION , <br /> Title Name,Address,City.State,Zip Code <br /> •.• •.• Sea _ • • 2 ' ' • •• ■ as .. • s . a .. . <br /> • A • • . .•. r.a. _, •_.• k .. . • <br /> Pli V s: •• ■ 4 a.. i_4• •• *- .d_ • a• a ..• sl <br /> • • • .. 111. • e l • il. - • . e,.,% :,,• .. _ a . . b. ., , a <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 /> 1aD„Imark -Pa•%r 20141 T9TX•5xNwT3 599GB2V22E142r6NGfiX 1-3)-2aKI <br /> Fnrd 1991 Pho55isi ell,wl_13&om1FL1 F41F.VEDE33341 3-11-wig <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ®Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> R_ <br /> Give detailed description of use,Including an explanation if multiple use classifications exist: Lt YES ❑NO <br /> 'TT—c UlSed c+ &f ) Q y jii nt 'b 916)"::\e- <br /> If No,give percentage of exempt use: <br />, (rknvar\enrP. <br /> 1ec <br /> use a5 tAe c�.ciO,\-y 4cc \c c sOe< <br /> -c, dalce 5coO'*;nt cA Oi4&5 -j'u Uo koct corrtrnoirt4te5 <br /> Under penalties of law,I declare that I have examined this:..lication 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 thin exem-,• :.•leaden,and that the organization owning the above-listed properly does not discriminate <br /> In membership or em oyment bas race,color,. -nal origin. <br /> sign -+I, 8eJ3ui Eyeeu-4-lv4 .3-'I-ILI <br /> here Authorized Signature Title Date <br /> FOR COUNTY TRREEA'S�UREER�RECOMMENDATION <br /> APPROVAL RECEIVED COMMENTS: ti�i"' ? wt ,2 ) �"�' 'C�' 77-4'o2� <br /> ❑DISAPPROVAL <br /> APR 3 2014 X`� V.-..9—/V <br /> Signature uny Treasurer Dale <br /> I HALL Omet FOF COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND,NEBRASKA <br /> XAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 01.AuNOdzed Signature C Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.55 77.202(1)(c)and(d),and 60-3,185,and 603.189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-2532008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />