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.----1"1730/2615 10:04 4024603221 GSS NAST EX DIR PAGE 02/06 <br /> ,.ice--z-- Application for Exemption 9)6 /CO FORM <br /> Nebraska()apartment of <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations 457 <br /> •To be hied with your county treasurer. <br /> Olf0PCRfV ass Dc16.mm m Read Instructions on reverse side, <br /> Applicant's Name lye*of Ownership <br /> GOOD SAMARITAN SOCIETY GRAND ISLAND VILLAGE ®Nonprofit <br /> Street or Other Rasing Address County Corporation <br /> 4075 TIMBERLINE ST HALL - E other(specify): <br /> City Stale Zip Code Slate Whore Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFR ORGANIZATION <br /> Thlo - Name,Address,City,Stale,Zip Dodo <br /> • <br /> • <br /> • <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> Attach an additional sheet,II necessary. <br /> -Registration Date or <br /> • • • Metorvohrds Rake ... -. - ModeIreear• . . •Sbd Type. - ' - - — `votee'IP aambi'r . - ... Dete-otAoIUu.ltlon,- <br /> If Newly Purchased <br /> c•D92Ei •Cf0". LO■nl\4anp L.x:kr) VIM/Yii,lLit-I2615. 1%21) t Loll aotl <br /> r x,' . . do• <br /> ►_.s is -_, off' a�.. . . .��ieri►w1elat'{-'l 4"'1 liff!i i rti_.o - <br /> y r e.r.- psi\72, .dam Ell a e u .�• Il : ► I IIMG'}/ - <br /> Exempt Uses of Motor Vehicle: • Amine motor vehicles used exGeslvey <br /> ❑AgriculturavHoNSuhural • ❑Educational 8.Reilgbwc ❑Charitable ❑Comelary as Indicated) <br /> INCREVA <br /> Give data scrlpibn of <br /> use.Including an explanation If multiple use classifications tions e xk y k,'r <br /> YES ❑NO <br /> lit- v R. +C- y P U Gutit- plO ittifir /vav+i" 7•1rk� ° If No,give percentage of exempt use: <br /> mV iJ 4 +AA �u�M, 4 a s 4 r � ` <br /> a/aG7lQ, 0` ' p•A, <br /> ' <br /> WXY ttorrapott <br /> J% �o , Oi 'f? it <br /> reexir Iry71!s . t- � ..lL 24..Q <br /> mid e r. n t Ai° ...44-,441141g 1, ii emu. .ie GQ <br /> d <br /> Under penalties of lawi declare that i have examined Ihk applicafievnd that tom an <br /> e hest at my knowledge and beget true,complete,and correct.I <br /> also declare that I am duly authofsed to sign mk exemption applCatlon,and that the organization owning the ebovo•Ilsted property does not diacnminate <br /> In membership/ r or employment based on floe,color,or national origin, z <br /> Sign LL Jt6.Lt.C.J u ‘q de °201 S <br /> here k Aulrbdy Signature • Date • <br /> �� �FOOR COUNTY TREASURER RECOMMENDATION o -.". <br /> APPROVAL RECEIVEC MMENTS: /'/-t--n 'z7 �e`._- <br /> /12‘.:`'. �� ` - <br /> �gV-Trirke tn <br /> es- <br /> El DISAPPROV M. Si°SFktiViL s. <br /> NOV 3 0 2015 ` `""�' °� % / ? 75 %� <br /> Signature of County Treasurer Date <br /> I HALL eni"TN FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> APPROVAL COMMRT'S: d/ <br /> El DISAPPROVAL k//{/////�/� 7 � <br /> r�gn' / ��11 �1a9, <br /> It Authof5rad Signature 4^t^ <br /> Nebraska oepetmenl of Revenue Adthodxed by Nob.Ran stet gg 77-20211)(c)mid(d),and 00.3,195,end 004,189 <br /> he-255400e Rev.9.2011 Supersedes s6-252-200C Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />