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iti''`—Z 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 /> mintiarnsi <br /> •Read instructions on reverse side. <br /> Applicants Name Type of Ownership <br /> ��n-kr tn.- L_; v :n <br /> y Nonprofit <br /> Street or Other Mailing Address County , + Corporation <br /> 33 A 1- LU' Cap' )P NE leW 4.( 4. II El City State Zip Code Stale Where Incorporated <br /> Other(specify): <br /> ( rctrk4 3 land( N E e <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,Stale,Zip Code <br /> P(e3 4 crtt I 7'rets . -flan ibis t,coa 'C'• tt -n't nisi;ni ,i e l0 •39 <br /> Set-rkt'ur1 in : fch C-reen&aff i(,pt rA:ifex- St 46I4rP t , LIE toX44j <br /> Anne-4 Taf-c- i;rut 319 xt• 111; rYt,en aue, e1:njen Qr.. (039 5'7 <br /> fire ref Al au(en„ Ihuninn X35 F.• al: l: Jar1 4uP rrPennot' )JE G;eas <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 /> Oleos, :S,npalr. I- ,005 y -cloor Scetart aGi u1il 55K 554,73ci 4tJ, f /x5 <br /> 4- , re/ Taurus 5 i a 00.7 LI-door Sxs6„ I(A f P53 u-X 7A/66i/56 7/ <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaliHort Edu <br /> icultural cational El Religious ❑Charitable ❑Cemetery as indi ated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: j214 ❑NO <br /> A non pro1:l aI'eOey phut .?ro sides a oar:ell ok <br /> It No,give percentage of exempt use: <br /> i nd� � ti S� n:-1.Carrt i <br /> Ser0;ces! "ED \j; duals w `/ <br /> cf:SG. L.f I: 41es It� ' n, ∎ n ci-h e; r homes and <br /> Corn r)ftfl; ;ems <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 O ,,,ttaz <br /> here Authori ignature Title Date <br /> / <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> an/Vat <br /> IL]1CPPRCVAL RECEIVED COMMENTS: at' -'�"//, <br /> aiicF. Se 7'--■?•=5.9_, <br /> ❑DISAPPROVAL JAN 2 3 2015 �p } <br /> 1% C /�` /- ...73-1,S <br /> MM 1 Cfx INTY ,Signature of 0 unty Treasurer Date <br /> TREASURERS OFFICE FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> pi APPROVAL (GLAND,NEBRASKA <br /> pd APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> /, // � . � / /017 /s <br /> I..'o 0.4,n,r�� ' Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)and(d).and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />