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In^.---e____-- Application for Exemption ;0 IFORM <br /> Nebraska Denanent 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 R I1 V Type of Ownership <br /> SERVANTS OF MARY SR RITA-KM:BERT ([ a I be,T ® Nonprofit <br /> Street or Other Mating Address '` County Corporation <br /> 822 STONEWOOD AVE HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tite (' per Kil.1 I APrr„Ness Name,Address.City,State,Zip Code <br /> s r. J as k. e v 4 "1 fed M : 1 atia r j /Aue- £'�ma, et kir 4I 1 3 y <br /> Il. . a IHi-er en ,fA ' ` o. AI All OS e_ d 4 6 • i.3 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> e Attach an additional sheet,it necessary. • <br /> Registration Date or <br /> Motor Vehicle Make ModelYear Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> fn Ertl 11149o(Or717 5oax re @, is zxy )FA FPSI+N751V07033-4 <br /> Exempt Uses of Motor Vehicle: .Are the motor vehicles used exclusively <br /> 111 Agricultural/Horticultural 111 Educational lig Religious ❑Charitable 111 Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: DYES 0 N <br /> { { If No give percentage of exempt use: <br /> Vet/ g; ous ,�iln lsff� anti reeky-Rd A , t ,,,, 142-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 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 /> here � PE U tere. 3o -3iq-1140 ( l—q, Don/ <br /> Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION IO� <br /> APPROVAL RECEIVE�OMMENTS: — T" �S -*-7770a. <br /> ❑DISAPPROVAL <br /> NOV 1 3 2014 J( /-t-i� <br /> /Signature <br /> Treasurer Date <br /> NAI I rill INTV FOR COUN—Y BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL I <br /> T <br /> 7" •iied Sig atu'if... Date <br /> Nebraska Department or Revenue Aulho,itel by Nets flee.Stat.g$77-202(1)(c)and(d).and 00.3,185.and 00-3.189 <br /> 96-2532086 Rev.8-2011 Supersedes 98-2532008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />