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� r.._- Application for Exemption FORM <br /> Nebrask.RPepertment of <br /> &REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> �/__ Co be flied with your county treasurer. <br /> canigranii <br /> •Read instructions on reverse side. <br /> Applicants Name C h I +� / - �}. Type of Ownership <br /> m,J /Jfar`4S Len ter toy' be4Q U:er4( Iiee[1-4 Care San✓/C ea IAA. Nonprofit•Street or Other Mailing Address County Corporation <br /> 6' S NC 'N✓ Jr Pa / di 6763 i[F(( <br /> ❑Other(specify): <br /> City / State Zip cC/ode State Where Incorporated <br /> Green i3le ncf OE 68Vo yVc. <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION , <br /> Title Name,Address,City,State.Zip Code <br /> Pies tSeta °eh) �d r, e , ,.lcr,-,s lids 3ae0-wvfr- Apra keo:.vG f WE 6 sty 7 <br /> UivPr€Ji--Ccd Pie tie54i gi0:3 Ponyty,reas- kd kaarve7 /i/ Gnu "7 <br /> see xt fin ,E'.ei eted <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make Model Year Re <br /> Registration Date or <br /> dyTyPe Vehicle ID Number Dais of Acquisition, <br /> d ty Purchased . <br /> Dorf Ca Cai0(cn Gr_...elyert _ aa)3 U5,1/CI+ aD4@P4i{i53R 'I. 17Q N fliN <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural E]Educational El Religious [` Charitable ❑Cemetery as indicated? j <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES ❑NO <br /> 'Tis Uc✓1l's kt°cl Jo +c-1n3 to/L CI,u1+s ' item se,/Ji-c �J�. <br /> If No,give percentage of exempt use: <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 property does not discriminate <br /> in membership or employment based on race,color,or ratio in. <br /> sign 9c /it)/1:«i /Z/ is <br /> here I Authorized Signature Title 4Z—Z. <br /> a e ( I <br /> FOR COUNTY TREASURER RECOMMENDATION <br />• <br />• �PPROV.L RECEIVED CO ' ENTS: ,F. , .c%S.S. "� . - - ae)a <br /> ❑DISAPPROVAL MAY 1 9 2014 <br /> ti� �=cia-ice <br /> • • Signature of County Treasurer Date <br /> • e'j �•j��y'j�•UNTY BOARD OF EQUALIZATION USE ONLY <br /> i <br /> APPROVAL COMMENTS: <br /> ❑ DISAPPROVAL "� <br /> � mntc c� /e5f <br /> Authorized Signature Da e <br /> • <br /> Nebraska Department of Revenue Authorized by Neb.Rev.StaL§§77-202(1)(4)and(d),and 60-3,165,and 60-3,169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> • <br />