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Nebraska Department Application for Exemption FORM <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 /> •tkant's ame / \ Type ofOwnership <br /> Oral Ph / wnari& cCiriV Egaprofit <br /> et JJ oOt1 Mating A s � <br /> rk / ad County / Corporation <br /> Ci txt d St Zip o? y 1 State Whe 19cporated ❑Other(specify): <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> T 1 :me,Addy(ss,City,State,Zip Code <br /> �.1/* �r■ • - mss' ir "' t�v • 1:, .I I ti <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 /> G oot<-14;li+y-trarto( el'10/5 -f/'a//or X eie /(o Alt-Ma»s>gf <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaUHonicultural ❑Educational ❑Religious Ch/aritable ❑Cemetery as indicated? <br /> 1 /Give detailed description of use,including an nalion;" m Ole use classifications exist: - �fES ❑NO <br /> Gels - ice' 'Me ' / <br /> // g � ��/� � !� If give percentage of exempt use: <br /> /G�i w/ / A �g °6 <br /> �� p� _ p i, <br /> ��� , �� v _ _ /_ . ��d'L.r/r (�y,� �6 i %��//�/,��//Under penalties o ,I declare that I have examined this application and that it is,tot - .-st of�kRSwledge ief,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning t sled property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sig n /�/ ��.� �! r �r,! E <br /> ZZ�S <br /> here P th.rized Signature f <br /> O, Tale Date <br /> FOR COUNTY TREASURER RECOMMENDATION JJ-// <br /> // ) 4 c_4 77 Qo a5 <br /> t PPROVAL RECEIVED°uMM ITS: jcvm nl <br /> • <br /> ❑DISAPPROVAL <br /> ry —"2441 /1-29-'5— <br /> JAN 2 2 2015 . Signature Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> nAU.COun rr <br /> TREASURERS OFFICE <br /> gLAPPROVAL GRAND ISLAND,NEBRAEKA••K ITS: <br /> 0 DISAPPROVAL <br /> r�/� l <br /> yf'o iz"•r P-'4!Fr - Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev Stat.if 77-202(1)(c)and(d),and 60-3,185,and 603,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />