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een� <br /> - 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 /> Applicants Name A Type of Ownership <br /> ,L.Gs' Prier^rC- ice.*a j-e,� C f T//SS _ c,Nonprofil <br /> Street or Other Mailing Address County Corporation <br /> Li 04 5 "t 'ii r r . S Y r-.... -'-r- Nu 11 ❑Other(specify): <br /> City Slate Zap Code Slate Where Incorporated <br /> . eIt »e rs/ar rid � - 1.-?Ye, i 1V&- <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> A <br /> . -) i <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 /> 0a G 9 r a e v y .2 D€ , . GLF /-141NgCa1 Yfl/f$ aZQQ <br /> Exempt Uses of Motor Vehicle: q./ Are the motor vehicles used exclusively <br /> ❑AgricuhuraMorticultural ❑Educational ❑Religious DI Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including a xplan ion If ultiple use classifications exist: ,�LZ(Z"c— '� 0-g YES ENO <br /> u hi a If No,give percentage of exempt use: <br /> Under penaltiesdf•w,I declare that I hav• ,. - ed this application and that it is,to the best of my knowledge and belief,true,complete,and correct.I <br /> also declare that 1 am duly authorized to sign this exe •ion application,and that the organization owning the above-listed property does not discriminate <br /> in-members t ad on race,color,or n:"anal origin. <br /> • <br /> a <br /> _ i /- <br /> ix <br /> ere Authorized Signature Title ':ate <br /> FOR COUNTY TREASURER RECOMMENDATION p. <br /> FrAPPRO'AL RECEIVED COMMENTS: ,EA^ ' � R / EN-' 4,,a,S. °° <br />• <br /> ❑DISAPPROVAL <br /> JAN 2 3 2015 t/Q_t.� /-_z_v__ s- <br /> /Signature of County Treasurer Date <br /> }ley ern Icy FOR CC UNTY BOARD OF EQUALIZATION USE ONLY <br /> 1 TREASURERS OFFICE <br /> t GRAND ISLAND NEB B,��. <br /> 0 APPROVV�ACr COMMENTS: <br /> ❑DISAPPROVAL /" / <br /> „Ada♦ �� e , :i/ } 21-jS <br /> .:fr odzed 7, r r' r' Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Shat.§§77-202(1)10)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 />