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Nebraska Department of <br /> Application for Exemption FORM <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 /> A/pj��,licant's Name �— ` h Type of Ownership <br /> l�bfX1W.U LTNAL S1rLGS CDC L4trc ¢s VNonprotit <br /> Street or Other Mailing Address © �.{ Q f - fl Corporation <br /> IOd4 7��. 1 �d�xl V�+� k\ ❑Other(specify): <br /> City State Zip Code e Incorporated G Ma- <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Pa ArrpreI b <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 /> m SI •..... - 111' •r: ■ - ._9+ .. . ' . 5 .. • a <br /> Exempt Uses of Motor Vehicle: �� Are the motor vehicles used exclusively <br /> as <br /> ❑AgriculturaUHorticultural Educational ❑Religious VLf Charitable ❑Cemetery indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: S ❑NO <br /> 1LSrd Crw— 1.a4.- 1,x.03/Cellr .t doc'oA-Iona <br /> If No,give percentage of exempt use: <br /> S c 0 r our a v3 Oi&A° - j ro5rca_ -s • % <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 authori sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment b n race, for,or nation num. <br /> sign cold-i-a�o"1� ate /- /41 <br /> here ►Autho if zed Signature Title Date a <br /> OR COUNTY TREASURER RECOMMENDATION <br /> [APPROVAL RECEIVED COMMENTS: 4 ' IC.'�/a ` 1 ar 77- -7e) a <br /> ❑DISAPPROVAL MAY 2 1 2014 //�'�/ <br /> NAI I fMllkn'1/ Sil, 9r1gitl o Treasurer Date <br /> 'TREASURERS OFFICE FOR ;OUNTY BOARD OF EQUALIZATION USE ONLY <br /> L ,!°RAND ISLAND,NCBRA9kA <br /> i APPROVAL COMMENTS: <br /> 11❑"DISAPPROVAL <br /> ► /mss net Q 41 wy <br /> Authorized Signature Da <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat§§77-202(1)(c)and(d),and 603,185,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 />