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Nebraska not Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> I •Read instructions on reverse side. <br /> Applicant's Name + C Type of Ownership <br /> ovQrlG r,r 1 s C61...,VN01 Iy l�G A . Nonprofit <br /> Street or Other Mailing Address Coup Corporation <br />• w \ ,. ,3� ' �6. (/ <br /> pother(specify): <br /> Ciity N� Ls lU.^. tic 6t�e1 State Where Incorporated NC <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> N '.'V T Ib ?fflfl A B '10, r e . Taw t�111111•ore,-, ...,•. Sher ' at t-A 3 _a _tan%a _ • 'q5 <br /> Effillgi ell.[ 0 .i r A. —I lb • _._. • • . ... ♦ . :1 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number Date of Acquisition, <br /> �^ B Newly Purchased <br /> —a1LTrnt3s, Lei la batter 55i-IF X1V241FMn Ibuftb 44-I+1-2,01' <br /> Exempt Uses of Motor Vehicle: I Are the motor vehicles used exclusively <br /> 111 Agricultural 1orticultral Er Educational 111 Religious ❑Charitable 111 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 1 YES ❑NO <br /> ("«1ec -. ;-- fX ' c5t O -�Q-k-)QnS a 1y <br /> ``} If No,give percentage of exempt use: <br /> �ame 0(1j0J Ind <br /> A <br /> U r•, 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 /> al-o declare that I am duly authorized to sign this-.A-mption application,and that the organization owning the above-listed property does not discriminate <br /> in mefobe•. emplo -• `'e r national origin. <br /> sign a- � ii ► _ `-1/613/i5 <br /> her- Y orized Tatum Tide Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVE�QMMEraS: ,.a mss 774'o <br /> ❑ DISAPPROVAL <br /> APR 2 2 2015 /Signature of County Treasurer Date <br /> FOR COUN—Y BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE <br /> APPROVAL GRAND ISLAND,NEBRABramacm-s: <br /> ❑DISAPPROVAL /// A / / <br /> A i r ;• Sig .lu : Dale <br /> Nebraska Department of Revenue Authorized by Nab.Rev.Stat.§§71-202(t)(c)and(d),and 803,185.and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supeisedee 86-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />