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9,016 <br /> a^ Application for Exemption FORM <br /> Nebraska Department of <br />• <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 Name Type of Ownership <br /> NORTHRIDGE ASSEMBLY OF GOD <br /> ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3025 INDEPENDENCE AVE HALL 0 Other(apeafy): <br /> City State Zip Cade State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Ot►_.rt t 8 r `t- •. I tt O►...1oejc • - G e -C•4 f. A - I. .,.rl- r - Yb03 <br /> i. .ecreka4- �MIni11p_ SChar{,{ 11v is 4r'stet,aSi. era..ii.TsiconL Ii L4iC3 <br /> 1 it 'Xleitl.rer rrtnv. .S4Gxlete a f '1SO —Co tt'e e.ck At,rt,,h. kica. /0fs.- t $ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br /> Registration Date or <br /> Motor Vehiele Make ModelVear BodyType Vehicle ID Number Dale of Acquisition, <br /> it Newly Purchased <br /> Fot:to a06u aC.CA,r\.A4 't• 4yr{I ,A iFt;SS3tLnn3xtsv1At <br /> F_tv4.e i94y C.14inioa H Cs 450 i t3353i A0614Ac44ob <br /> ( ..cASSiC, jG55 Evjaseo0 Tc ea.\-ei iowAF�2 $ U)b:1098S <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturalMorticutWrel 0 Educational Er-Religious 0 Charitable 0 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: tn!.. ES ID NO <br /> cc r� ���`� ��� \ n 4,i� *o Ci k1£ F't Cyy. If No,give percentage of exempt use: <br /> `r\D OC�\r'Y� tIJ Jy <br /> c e_V,5 t O�..S etie 4. <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 national origin. <br /> sign ✓I0 <br /> here ..A, filcite,, asyckyr1 1 -'2 -* <br /> Ihori A,d Signature Title Date <br /> FOR COUNTY TREASURER RECOMM NDATION <br />• <br /> PRQYAL RECEIVEaOMMEh TB: '671/779dat ' 77 aO4 <br /> ❑DISAPPROVAL <br /> NOV 1 4 2014 <br /> •Signature of County Treasurer Date <br /> TREACURCOOU OTY FoR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> - <br /> V_ GRAND ISLAND,NEBRASKA , <br /> APPROVAL COMMENTS: <br /> ❑_DISAPPROVAL <br /> /kit f4A,_ l . i / / 13 -15 <br /> thoriz-,ri,n. re Date <br /> Nebraska Department of Revenue Authortted by Nab.Rev.Stat.§§77-a'02(1)(c)afro'(d).and 80-3,185,and 60-3.189 <br /> 96253-2006 Rev.5-2011 St,ersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />