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9415 <br /> sass,- Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •To be Bled with your county treasurer. 457 <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> GOOD SAMARITAN SOCIETY GRAND ISLAND VILLAGE ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4075 TIMBERLINE ST HALL ❑Other(specify): <br /> City Slate Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> I IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> OA/ 111(4° ( <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make ModelYear 'I BodyType Registration Date or I Vehicle ID Number Date of Acquisition, <br /> 1 a Newly Purchased <br />• <br />• <br /> 1 i ii 1 ► Q <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural El Educational E Religious ❑Charitable ❑Cemetery as indicated? <br /> ( ' b EVES 0 N <br /> 7} 04471/a kfraje in" rat If No,give percentage of exempt use: <br /> � f Lr� m-, -� PL )- 4 . 9.74 `e <br /> m ' ' ; i f r21.4 <br /> 9771,�/ �• f �s �t / mss . sd be ieieft . <br /> J�a�+'��.���JJJ Unit enahi of law, declare that I have examined this application and mat a ,to the best of my knowledge Ind belief,true,complete,and correct I <br /> 44 "/ ' also declare that l am duly authorized to sign this exemption application,and tl he organization owning the above-listed property does not discriminate <br /> ///---"'���+ / in membership or employment based on race,color,or national origin. /� <br /> C sign SaT ` a ti- 1.ca�=fnct�i irehr 0 ture Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION' )� <br /> • APPROVAL RECEIVE&OMMEh TS: "•' ' 4 4*77--.7O-Z <br /> ❑DISAPPROVAL <br /> NOV 2 1 2014 ( �qy6)1 /- eP' i� <br /> i'Signature of County Treasurer Date <br /> 1 lint COUNTYFOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> 92 APPROVAL MMtNTS: <br /> ❑DISAPPROVAL <br /> f./;s%szsitr l� f/" Is-f.5 <br /> .'F onzed •n-ture -��' fate <br /> Nebrasle Department of Rwenue Auttnrbad by Net.Rev.Set.§§77-202(1)(c)and(d),and 60-3,185.and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96.253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />