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ie„• ---r_- Application for Exemption FORM <br /> Nebraska Depenmem 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 I////�L^^^��rr �rL—' Type of Ownership <br /> Or vrrtr ,v `Y1*CA/ ,Nonprofit <br /> Street or� ailing Address <br /> Corporation <br /> �7 j Ffi y Q r C GtG County � <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> C€nW rSl. wp my 6 SJ we <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Lp Code <br /> 6Af+/QC rY MRNAc6/2 CAR.y G2)e arir ar Srf4zgcoAr,/g Rs re.2T ills 65-5c1 <br /> kisr L/t.vea.N' ,oFle fro 3Y " Air- errea,-/v-e2_ N!. !o G'j'IS <br /> _ < < �,� - kdN ,t'0-6),(4764 , Sao cv;i/scar Sr, fl&e /f:toyr_6??os <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Bodylype Vehicle ID Number Date of Acquisition, <br /> _ if Newly Purchased <br /> // *W. f21`4-Mtit- gel 7.-`:(Pt, .s'33Sc/.z// c'=c&5r8' _ 7- 7 -/5 <br /> &93 <br /> 2oo6 Gel -7-Y041 .2OC 2 tcaace re.fObT7c1n t7'ora2. 7-/- J4- <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> Charitable Cemetery <br /> as indicated? <br /> ❑Agri <br /> alWrekHoniculWml ❑Educational ❑Religious ❑C <br /> Give detailed description of use,including an explanation if multiple use classifications exist: EiC'ES ❑NO <br /> USEL for Ic,ue9rrei.ni gcli-„c e-5, 54[gee- . t Ii-¢C- <br /> ire iks RArp Ccr-�@e9,o't PeuasT2rOP O r c. 1O f fNo,gvePetentageofexemptuse: <br /> �! 1 So Pt;e ' l3/d-4J r-lo cif eho/d Go acts } Ag '`�'- v, <br /> /`11 z 2 C� <br /> CeKt f-ra•.L w e <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 properly does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign ' c,� .ir.• fiut-,toij 8 r 7 -07 7 -4( <br /> here I Authorized Sign re Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br />• <br /> 4PPROVAL RECEIVEQOMMN . ee rn yzt,00.4AJ-q�, 1e77—....7.c...2_, <br /> El DISAPPROV)L <br /> Jul 2 7 2015 vW ..) .7: g8=i-S" <br /> Signal aunty Treasurer Date <br /> TRFARfIRFRC A <br /> fiA'1GOutng COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND.NEBRASKA , <br /> 777APPROVAL COMMENTS: <br /> ❑DISAPPROVAL �� j ' <br />• <br />• <br />. /✓d,.� ft... . '- ' g-//-/L) <br />• <br /> orized Signature A� �� Date <br /> Nebraska Department of Revenue Authored by Neb.Rev.Sat.§§77-202(1)(c)and(d),and t0-3,1as,and 80-3199 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2009 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />