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Dec. 15. 2014 1 :30PM No. 6776 P. 1 <br /> --z-- Application for Exemption FORM <br /> Nebraska Departm;at <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> sib be tied with your county!Ensurer. <br /> canciammasi •Reed Instructions on reverse aide. <br /> Appficanrs Nam `� ff Type of Ownenn4 <br /> 1 Mid .. M beta S1&a 1 riri 1 trteL G41 _5arl/ lc re5 ❑Nonprofit <br /> Street or Other Mailing Address County I Corporation <br /> a s 3 C. C Gar t o 404 �l u ore 14 a ■1. p other(specify); <br /> Cly State tip Code State Where Incorporated <br /> G tr,d..%N A ( $l o..v‘C., N Z b 8 103 N c <br /> 1 IDENTIFY OFFICERS,DIRECTORS,CR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tale f. Neme,Address,City,State,Zip Code <br /> C){,aitcryan ..ruta.rt K alto Po 13X 139 Gr 6 g Al S FS Li- <br /> 1/ has 4' .ejlrntav cm,fd / rpetn .3 21.0 12 (C Ie Sen a 6 896 T_ <br /> e c/ r^eci ten ftt CetaK U £ ate 6 8�twe.z +` <br /> 6 , •_.rut , _ W mWW taPit e- a( <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,if necessary. <br /> Registration Date or <br /> MotorVehicle Maker / ModelYear SodyType vehbielD Number Nale of cqulmson, <br /> „lei rc%r er.0441- t. <br /> 1 . <br /> Scampi Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Arstult tiYtardtvtdaaf ❑Educational ❑Relgbua @cnadlaaa ❑Comte, as indicated? <br /> Give detailed deacripfion of use,including an explmwdon if multiple use classifications test J ®YES ❑NO <br /> 1'a tro.n r port d e Oct oprnenfa (5 el sa.b (aa ttNaBneparcanagoaemmMuse: <br /> 6In� : Jidtxc.,( S. c<t14. er0yedie SJery Ice s 7. <br /> Far e.7v- pi6a WPC.K..(. _ <br /> Under Penalties of law,I declare that I have a amitad this epee:a don and Malt Is,to the best of my knowledge and CAW,true,complete,and canna I <br /> also declarehmtl am duly aueimizedto sten this exemption eppicatbn,and that the agenizetion owning the abovoislad property does not discriminate <br /> In metabwsnlp oremployment based on race,cala,or radonet origin, <br /> sign hAL,LA i 6,214,„ x_.. nu fret, 0 i re don- ra (5,4f <br /> here ■ <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> ErAPPTAL RE r ENTS: . .r�Ais.s, 4177-.1042 <br /> ❑DISA AL RECEIVED <br /> DEC 1 5 2014 „,,, a County set—�K Data <br /> /-y-75--- <br /> • <br /> I FOR NTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNT/ <br /> APPRMAL <br /> is ISLLANDS BFRASKA CO MENTS: <br /> ❑DISAPPROVAL • <br /> lire/ : .2 Ai !g-6 <br /> cr?':,. =-r r- lire <br /> maws oeperrmantsr Revenue A lheemd by Nab.net Stare 54 naoa(i$(4 and f4 and e69.1as,and MAO <br /> 964594006 Ms 84011 Suporsadas 944552000 Aim 52005 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />