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�^--L- 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 /> Applicant's Name Type of Ownership <br /> TEHAMA SHRINE/CHENTRAL NEBRASKA SHRINE CLUB ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 5575 S ENGLEMAN RD HALL ❑Other(specify): <br /> City Slate Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> PRES WAYNE WREHM 2777 N BROADWELL AVE GRAND ISLAND NE 68803 <br /> TREASURER WILLIAM CARSON 5575 S ENGLEMAN RD GRAND ISLAND NE 68803 <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 /> DODGE RAM 2002 PICKUP 1D7HA18NX2S571594 <br /> SNBD 2010 TRAILER 5NHUSNZ23ANO69814 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaNlorticultural ID Educational El Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation If multiple use classifications exist: ®YES ❑NO <br /> USED TO PULL TRAILER WITH GO KARTS TO PARADES TO PROMOTE SHRINERS <br /> If No,give percentage of exempt use: <br /> HOSPITALS FOR CHILDREN <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 r,or national origin. <br /> sign TREASURER ta)lce <br /> here I Au horized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> QL?CPPROVY RECEIVED COMN RE B <br /> ENTS: ` ", At EN XS'S" 77 so Y <br /> ❑DISAPPROVAL <br /> DEC 1 5 2014 ai°dPa_as.0 /- 9 ir" <br /> Signature of ny Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL 1..OUN IT <br /> TREASURERS OFFICE <br /> I-7rl APPROVA. GRAND ISLAND,NEBRASK ,ENTS: <br /> ❑DISAPPROVAL - <br /> o! /i 1---/3 45 <br /> •'thorize:Sg' ture - - P't Date <br /> Nebraska Department of Revenue Authorized by Neb.Rey.Stott;T7-202(t)(c)and(e),and 60.3,195,and e0-a.189 <br /> 96-253-2006 Rev.13-2011 Supersedes 96-253-2006 Rey.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />