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evn —z-- Application for Exemption U/ ( 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 /> NORTHRIDGE ASSEMBLY OF GOD ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3025 INDEPENDENCE AVE HALL <br /> ❑Other(specify): <br /> City State Zip Code Stale 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 /> ?gess Deily MA 2K (43,523erg '903 SACe-wc D 4 vE ;6,a4 D 2$Z.w, iv£. &, 9'�2z <br /> j21A5vea. /tt, jt .57 -)bil �' 9So i�RA2/ERof' IIuaaU)J% 2PE/K <br /> se-c2t jAtif mtll �hfsF• '/6/S S. A-2 ve sr,Get tX0 .35wi!)2kt 6fla3 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> IRegistration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> it Newly Purchased <br /> F09-Q Zoo$ ektokn. W lFass3/Lzaaszssll¢ <br /> prrfL <br /> 1R c15 Citki,llA4-�. L3.So !F8T53/ HosII EtT4o6 <br /> CLA5Sic- 1485 crefecr$ue-fit fla^ lowAE'E VC Woz oRPS <br /> Exempt Uses of Motor Vehicle: �-,r Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural ❑Educational nc.l Religious ❑Charitable ['Cemetery <br /> as�indd rated. <br /> Give detailed description of use,including an explanation if mulple(juse classifications exist: W YES ❑NO <br /> 4iv� 1n <br /> --', ^ Q Ma. tr V 1, If No,give percentage of exempt use: <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 properly does not discriminate <br /> in membership or employment based on race,color,or national origin. n <br /> sign i tow i'r„s3 /l�urk /Z 2-J5 <br /> here ,Authorized Signature Title Date <br /> FOR COUNTY <br /> TREASURER RECOMMENDATION <br /> E APPROVA GOMVMENTS: f`:7ASe /2,A> 4 <br /> L .:4 7 <br /> ”- - <br /> E E E D J..TfI844 <br /> ❑DISAPPROVAL . / 4 r <br /> [2 t. 715 <br /> /Signature of County Treasurer Dale <br /> FOR CC UNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> �/ TREASURERS OFFICE <br /> nQ APPROVAL GRAND ISLAND,NEGRASK mENTS: <br /> ❑DISAPPROVAL <br /> i aS <br /> Aut rized Signatu a - _ <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.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />