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aen---�- 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 /> Applicants(Name,t , 1, `-�. // C Type of Ownership <br /> M 14- IVCir0.S kw .1nA)U: dcr.4( Set-IV tcas <br /> 0Nonprotu <br /> Street or Other Mailing Address JJ p County ! / Corporation <br /> 2 S 3 (i C Q...r ire.T 6 L. A v e-- H 4 1 1 ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Ga-ci•-‘4et l 5(a.,,,.A. N E 6 aa6 3 P <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> GI.o.t . teno.vi. Rvo.w K(ei'fn PO Bx 13q 64ban. .u£ 6 SSat-1 <br /> Vice C- .a_t1- was-,•. RrnoLI ra c? 3967 At Nelsoq. ,O& 6 8q4 t <br /> Sec / rr'ea.lc�rcr Act lea era& 21,17 A. S1 C ,VE 6 886 2 <br /> (J0- 6 � i0-vtc ea_anfybc►1 2I6 ,u' Deaver /l c t c 7% NE b ?? ( <br /> 1. <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear Rode Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> 'Oo•tctc .2 6 t3 c1kr (A )s9, .ZC4ROGC6SORS-27.217 7S/t1, <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgrictitarauNonicumxal ❑Educational ❑Religious R.Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use dassificalbn)s exiet: / [AYES ❑NO <br /> T D T -o•klt s p c t-t de 0 c(6 A III tin-C411 td 1 S 410 (t 0-i If No,give percentage of exempt use: <br /> 1niu: d -( s a-.,,,.. IProuIcic Ser , ices sc <br /> racr t $% )lo •. m s ay ` , <br /> declare Under penalties of law,I tat I have examined this application and that it is,to the best of my knowledge and beet,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 /> ki membership or employment based on race,color,or national origin. <br /> sign o e_,L.c 0 aim-7hr 1.,1,.-,��, Aera Di r�dw- c Li t o <br /> here 'Ale ized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> jA4SV21a3N'ONVISI ONY O <br /> APPROVAL ALNROSOOT1Y14 W. COMMENTS: ^�'— - J '5 €. 77—....7c.2... <br /> ❑DISAPPROV tL <br /> #W'�'n r _ ES <br /> 7 itit 9-.sue-Y <br /> -�� Signature of County Treasurer Date <br /> 03A13/�1�Y 1 FOR COUNTY BOARD OF EQUALIZATION USE ONLY I <br /> APPROVAL (( 11/ COMMENTS: <br /> ❑DISAPPROVAL <br /> • Authorizer!Signature Da <br /> Natasha Depadmert of Revenue AWwdzed by Ned.Rev.Stet§§77-202(18e)and(d).end 603.185.and 80-3.189 <br /> 962532008 Rev.8-2011 Supersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />