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��- -L— Application for Exemption 1 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 /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> MOSAIC <br /> ig Nonprofit <br /> street or Other Mailing Address County Corporation <br /> 2846 OLD FAIR RD 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 /> Title Name,Address,City,State,Zip Code <br /> Jed- 77 ./1.hoh <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> I Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> If Newly Purchased <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> Agricultural/Horticulturaf Educational <br /> // efgrous ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it mutt pple��`��`use classifications exist: ]YES El NO <br /> I '/. _ / f �./ /I If No,give percentage of exempt use: <br /> !l/K// (JC•�J % <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 l 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 /> ���� � l! . _ .0.071n.4) / -699,©— <br /> here Author; The r Dale <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> [✓]APPROVA. RECEIVED <br /> EL COMMENTS: L.:FC-9y/11- 4"J =i <br /> c3 42-1- <br /> • " <br /> T <br /> i% <br /> Jaty 9 <br /> 0 DISAPPROVAL r v eta <br /> MALL COUNTY 01'Signature of County Treasurer Date <br /> TREASURERS oFFICEFOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> """' <br /> APPROVAL COMMENTS: <br /> El DISAPPROVAL <br /> aq/�/5 <br /> Awl zed Signature SW Date <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 /> 96-253-2006 Rev.5-2011 Stpersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />