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+e^-z— Application for Exemption 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 /> mit •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> SERVANTS OF MARY SR RITA KOLBET ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 822 STONEWOOD AVE HALL <br /> El Other(specify): <br /> City Slate Zip Code Slate Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> / IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> TftIq In K IA Q r/ ,,.-.ja r 5 Name,Address,City,State,Zip Code <br /> Sr, ,tae ; e yarL 9960 y ; art, A e Choi ho,- NC La i3W <br /> d e r e,, i h• Q 4. I i ' ; • L • S . 1 ' I c - 8 I3 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it 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 /> Ft,ra 1319tTokg617 1. o0 b ice145 ZXq AFAF_ 34JJ75-W2.o3054 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> Y <br /> El AgriahurapHorticufural El Educational Religious 01 Charitable El Cemetery as rid rated? <br /> Give detailed description of use,including an explanation It multiple use classifications exist: 4ES ONO <br /> y. /{7, l e l -d ,C I i 1.14 ) 2 s If No,give percentage of exempt use: <br /> �Q I j 1 6 L{S r 1 l"I t.S�/ �,. a i 1 I I % <br /> Under penalties of law,I declare that I have examined this application and that It is,to the best of my knowledge and befef,true,complete,and correct.] <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. <br /> sign /£, & .Reer 377- 8.140 ,f-0.e r , �Aci_ <br /> I / -9-)-015° <br /> here <br /> Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION 1 <br /> APPROVAL RECEIVED COMMENTS: dgit i lJO - /2-W /v 957�" <br /> $. X 77 Se:),:a. <br /> fit\ G <br /> 0 DISAPPROVAL d R . <br /> C�^, A <br /> NOV i 0 2015 [. °r 1 LP- fd- /-- <br /> /Signature of County Treasurer Date <br /> t ALL COOguNTY OR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND IS iLANDSNBRAKA J <br /> 'APPROVAL COMMENTS: <br /> ❑DISAPPROVAL / <br /> Signaiu / Datw' l <br /> Nebraska Department of Revenue Authorized by Nth Rev.Slat$5 77-202(1)(c)and(d),and 603,195,and 60-3,189 <br /> 96-253-2006 Rev.8-2011&veraedes 96-253-2006 Rev.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />