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en--Z— Application for Exemption 2O 1 FORM
<br /> Nebraska Department of
<br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations
<br /> •To be filed with your county treasurer. 457
<br /> •Read Instructions on reverse side.
<br /> Applicant's Name Type of Ownership
<br /> NEBRASKA DISTRICT COUNCIL OF THE ASSEMBLIES OF GOD ®Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 1503 W SECOND ST PO BOX 1965 HALL 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 /> PRe C6e.,,,.k Ro\acnt 4n21.,;t ?Cl e_ 541--Si. kec.,a.&ey NE CsG&41
<br /> SCULCkz4ky h .ze-SURert Tej'i'2.4 \'j Low,.. As-0 foxy Ittvc (." tc L,vtccly, NE &g. 5-0,4
<br /> tP.ct.:6R- Cori, i-4<-1Y + cto9 T yevz;dye. DRhte,. Pc-p i1.o . AJ (oK13A
<br /> 1);kecA-eR St-cue_ lnJc.,AZ;..eai 31-fl( diev 4 &c & .a-sj4...d me (s,S$c3
<br /> DESCRIPTION OFTHE 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 /> r e v 0.i-}a skeet --f-hr 6 R_ to 'J e In i C.l a: S
<br /> Exempt Uses of Motor Vehicle: �,.,,/ Are the motor vehicles used exclusively
<br /> ❑AgriculturaVHorticuftural ❑Educational IRelgious El Chartable ❑Cemetery as indicated?
<br /> Give detailed description of use,including an explanation If mutlple use classifications exist: WYES ❑NO
<br /> 111.,74 c- in-(,al)c5 CAJ c. .jSC 3 '-it ¶it n as#o P.c... C-Cf-ke 4r:' °v"- f^`°R-a.
<br /> p, 4 300 CR. Y••S 4'C/ZS G.ClLO c5 If No,give percentage of exempt use:
<br /> -1 G...L W C�v P-C-ke.ZS WA,d- WVOR.0 f-tn �J %
<br /> (AG,-Et o-F i1 eltvgc..sK�. '-(1.t_i. (AAA_ use i o gyros
<br /> AA t r�d e a
<br /> 1 N-Pl.wek-C D:S\'2'ct- e-uewkc t Cetw (151 Cohve ti-{-;D.SISetwt rV.-c,.t_5,
<br /> CA-C. Co.AA-c,th- 04 e 3okK E ws s'o 384— ,234
<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 /> sign ,
<br /> 1 .. � e tTSf�v�. � 1I - )u - t ;.
<br /> here I Authorized Signature Title Date
<br /> F FOR COUNTY TREASURER RECOMMENDATION
<br /> E APPROVAL
<br /> RECEIVED ` 7' ; t' c5 Q __
<br /> ❑ DISAPPROVAL � �y °fit:rtct 4
<br /> r ,x
<br /> /Signature of County Treasurer Dale
<br /> A.SU RE ERS OFF OF F.n-
<br /> TREASU OR CO JNTY BOARD OF EQUALIZATION USE ONLY
<br /> GRAND ISLAND,NEBRASKA
<br /> XAPPROVAL COMMENTS:
<br /> ❑ DISAPPROVAL .
<br /> 1 Veldi'r -1�1Lr. !P
<br /> A orized '.nal rate)
<br /> Nebraska Department of Revenue Authorized by Net Rev.Star§§77-202(1)(c)and(d),and 60-3,185,and 60-3,169
<br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Ray.5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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