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TO BtlLED WITH Application for Exemption FORM <br /> YOUR COUNTY from Motor VehicleTaxes <br /> TREASURER by Qualifying Nonprofit Organizations 457 <br /> •Read instructions on reverse side <br /> ipplicconnt's Name ,� \� ` _`(` /-__ 1 -., 1I,, 1' _ County cl I 1 Type of Ownership <br /> ....✓ Gt>' n\\ Inclower'I ce3 tic Vl!"fe6 !6r&oka�hc. AA l_-l._ �JIOnp t <br /> Street or Other 1Mailin Address��` ��` �� /� (� ,/ o/ County Number Corporation <br /> 1//0o`Y St, QT�Q{] `TV, PAC) Gt�C7/� 1O1g03 ^�_ ❑Other(specify): <br /> Cry l7�QYYS \ l `and , IV C State <br /> p�dOl State Where InwrPOrated <br /> 1, <br /> Identify Officers,Directors,or Partners V` 's <br /> Title Name,Address,City,State,Zip Code <br /> Per P *#rv'!st5r) <br /> LIST SPECIFIC DESCRIPTION OF THE MOTOR VEHICLES -•Attach additional sheet if necessary <br /> Registration Date or Date <br /> Vehicle Make Model Year Body Type Vehicle Identification Number of Acquisition if Newly <br /> Purchased Ric-S1100 <br /> C\\£vroL£T tea \blA_ .1titg Mo1:61 LGM-5SLIDEF23g940 "1logJts" 3O'bj <br /> Ris-31toS3 <br /> Ct1tvAn1-5.-T acts-4 MAL bu. tAtteSSL1 £fao1919 -tfoct/IS 3044' <br /> fi f 51.104 <br /> C NgVRo Lst 020 t5 C.Etat- 'GI PA551k 5F?1al an -"/to/t5- 3Q1 <br /> Nature of Use of Motor Vehicle: Are the motor vehicles used <br /> o Agricultural/Horticultural Nr Educational ❑Religious ❑Charitable ❑Cemetery exclusively as indicated? <br /> Give detailed description of use,including an explanation if multiple classifications exist: 1- g YES 0 NO <br /> �-,ea 'r6C �tr14LN Ls- ) Q�p e k103 c Vte r46 1ho If No,give percentage: % <br /> Or Q.l N CA_. Q Cia�ssi`J_t0 -- \�'7Tt C..ti co_Y\T5 . &ct \Ju\I'LS. py <br /> C 0`. Under penalties of law,I declare that I have examined this application and,to the best at my knowledge and belief,it is correct and <br /> complete.I also declare that I am duly authorized to sign this exemption application,and that the organization owning said property does not <br /> discriminate in membership or employment based on race,color,or national origin. <br /> Sign C'Sq.o Jv•, AC ,..0: (1A o _7_12111K <br /> here , horded Signature 1 Title Date <br /> I FOR COUNTY TREAASSUUR�ERR'S,RECOMMENDATION <br /> "y� <br /> APPROVAL RECEIVEaOMMENTS: 2 C ?V ' 42 ' - "CS. 414-77-.07® <br /> 9 DISAPPROVAL <br /> JUL 2 1 2015 e0t 7,,9/,V-3"-- <br /> • Signature of County Trene+'rer Date <br /> TorHALLLOUN t COUN"Y BOARD OF EQUALIZATION USE ONLY <br /> ALL COO I I I <br /> GRAND ISLAND,NEBRASKA <br /> • <br /> APPROVAL COMMENTS: , <br /> 0 DISAPPROVAL ' -/ 7 <br /> r <br /> Authorized Signature p <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stan§77-202(1)(U(d),480-3,185§60-5,189 <br /> 96-253-2006 Rev.5-2009 Supersedes 96-253-2006 Reel t-2008 <br /> PLEASE MAKE A COPY FOR YOUR RECORDS <br />