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mak.--1-z Application for Exemption0'/ ( FORM
<br /> Nebraska Department of
<br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457
<br /> •To be filed with your county treasurer.
<br /> f •Read instructions on reverse side.
<br /> -
<br /> Applicant's Name Type of Ownership
<br /> HEARTLAND LUTHERAN HIGH SCHOOL ®Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 3900 W HUSKER HWY HALL
<br /> ❑Other(specify):
<br /> City State Zip Code State Where Incorporated
<br /> GRAND ISLAND NE 68803 NE
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION
<br /> TT/itle Name,Address.City,State,Zip Code _�.( (
<br /> C.i,...r\i£5 '*:,'; XV_s__. 301 -<t'.r,it'�-c-Y`-,a ].�YyC, . tC`4ri�Y�en�7�10— \--)E- (sc -c�1
<br /> 1..^r�&cr.�. L,cc, Y\ ?- (m) c\C:.'mne c� m ,_c.,c,or' 47yt t e- Yi. (LCrc-(l?
<br /> `�(YaC.-:c-1 A „. ,fr`tV'm 35t etc Y<.AAS.0 . i k- 6.r!\a. �mrC or__ _(a °�
<br /> t•!' ( .1�kh`cam_ c =^1 }(4n---c-c-,._ , 1. <- i'IY C�iI f(<V 1 lri (C JA �
<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 /> if Newly Purchased
<br /> ' NP.; ;.`c.JV r`ra cm 1S'GA Ls,,.c.�v.. 'C�c.r, clef I to-Xe\Q∎C ), 1p
<br /> Wx'>mt .--D QCX1;') L --tip- e.;:m v_C-- X13\\3\S33t-I
<br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively
<br /> ❑AgricutturaVNonbultural 'J Educational ❑Religious ❑Charitable ❑Cemetery as indicated?
<br /> Give detailed description of use,Including an explanation it multiple use classifications exist WYES ❑NO
<br /> ir- r �+-¢-- �JC7\� r VAC�_. C$' `S(�f4.�� s m t'ILL If No,give percentage of exempt use:
<br /> i 'r`LV.L CCN.Is st0 CA"Th „ t"Y--, CaLSMO \ &C VIV∎"S-C'%-- ',
<br /> cc,-cc -C- C.V ,>`:.> ', °C..--C.-C' •
<br /> Underpenalties 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 national origin.
<br /> sign ' fir ✓ 1ko( AJC A.', fv2,/ c
<br /> here Authorized Signature Title oat
<br /> i FOR COUNTY TREASURER RECOMMENDATION i
<br /> 26PROVAL -. ga Ar<, COMMENTS: ^- -- ,- a{.-.p'”
<br /> .vi.vLrei iw. xTRf
<br /> ❑ DISAPPF OVAL // ^ _ F.:P0%Ft CEAr
<br /> /Signature of County Treasurer Date
<br /> HALL COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY
<br /> i le EA•S'unE.'CJ d,rrruE
<br /> GRAND ISLAND, NEBRASKA
<br /> APPROVAL COMMENTS:
<br /> ❑DISAPPROVAL
<br /> Li %%[ L
<br /> miry. Si. atu,er r r •.-
<br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189
<br /> 96253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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