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qt^--z Application for Exemption 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 /> cErimnamimi •Read Instructions on reverse side. _ <br /> Applicant's Name Type of Ownership <br /> IGELSIA DE DIOS EBENEZER <br /> ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 502 E CAPITAL AVE PO BOX 486 HALL <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> ct. S w i, +1 <br /> ►IINFREMIIIIrlitril -ilk <br /> 1 ► 1 .13E E ^ , ', ,}t- <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 /> -- C_ (-, \Cc the " b . 1 •, _ P, <br /> 'z" ,^ - Ws 'i) -":-00 —, .. wt. fib .fi "utmesmteri tit. <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricutturat'Horticultural p Educational laReligious ❑Charitable ❑Cemetery as indicated?Give detailed description of use,including an explanation if multiple use classifications exist: 'RTES ❑NO <br /> • <br /> ,t 1 -,r i ._n 9 �• If No,give percentage of exempt use: <br /> L )1 a I Lk-X.' \ " Sg)i 4C‘, <br /> --- t\)uS `,S \ C; t:� 1 \'v c�, 13Ti cLc 1 1 k \ C` (1 <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 property does not discriminate <br /> In membership or employment based on race,color,or national origin. <br /> 1 <br /> sign ; " \ �` ` \ c' o , ; % U <br /> here 'Authorized Signature - i Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> • <br /> APPROVAL c.Om"RENTS <br /> -71 r-- - 7--` -- — <br /> RECEIVED .04 ergs, <br /> l.,, Ici ,El DISAPPROVAL <br /> -yI rt � s , :" <br /> . <br /> WSignature of County Treasurer Date <br /> HALL COUNTY FOR CC UNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE j <br /> GRAND ISLAND,NEBRASKA 1 <br /> APPROVAL t, lvt�tENTS: <br /> ❑DISAPPROVAL ��_.. /( j <br /> nA orized S.. a Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.li§77-202(1)(c)and(d).and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />