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Application for Exemption FORM <br /> Nebraska DepartTVA 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 Type of Ownership <br /> 7/h1091621 an I ilk' CAT D PI'a an 1& ig Nonprofit <br /> Street or Other Mating Address,7 County // Corporation <br /> 361/1 0, Fa yd/&z. Ode, /-t4// ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Gad island NE -G 88o/ AIE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> P'Es/JE r , -Ayr! C : T., h, ,rls/n kE 62:o <br /> birsta 4&442 -. _ _is/a/n e A -::o i <br /> 1 ' A. r _ - ,-ay s/. i . E . : go <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 /> _ ft Newly Purchased <br /> H f- /l 0719 l5 7x/(0 Ena/nso(I 533TCI6aa1PC21c/368o z/-aa-15 <br /> TrQi ler <br /> Exempt Uses of Motor Vehicle: El Are the motor vehicles used exclusively <br /> ❑AgnwlturalMonicultural ❑Educational El Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it/multiple use classifications exist g YES El NO <br /> Thrs "fader b.) 1 b-t (L� -f0 fr&nsport 05([)p/,Qs G.noL If No,give percentage of exempt use: <br /> e uipnien/ So and - )-oni cAunets -acir/i-/ies and aefivihies, % <br /> 1. iv/ l( also be 0sed assis/ in G�om mom i/�, oa/teachs ' <br /> � <br /> an d g e✓fit? 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 n ' al origin. <br /> he a ,a, . .• / , Ad asides.— dasiness Aim inish-a-lar I/a9-/5 <br /> orized signature 0308-3:7- x/36/ "le Norman Al file C i44 y-- Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> 2 APPROVAL COMMENT • %y�rntiar ,atv /1141S- it 77- �&) <br /> 0 DISAPPROVAL RECEIVED <br /> V�''(p' //- 9c —... - <br /> APR2 9 2015 Sig�unty Treasurer - Date <br /> I FOR COUN BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY' <br /> R NSURERSE;APPROVAL FB� K 1EN :OD iI �NON <br /> ID DISAPPROVAL <br /> s/, / <br /> l / � �e// fr os-/��--- <br /> <zed s I at, - • Date <br /> Nebraska Department of Raven ANhbriied by Neb.Rev.Stat.¢§77-202(1)(e)and(dt,and 6e3,t89,and 803,189 <br /> 96 253-2006 Rev.8-2011 Spenedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> • <br />