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.,,,^--Z— Application for Exemption ay 0/(a FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •Read instructions on reverse side. Applicant's Name Type of Ownership SISTERS OF THE HUMILITY OF MARY ®Nonproflt Street or Other Mailing Address County Corporation 720 STONEWOOD AVE HALL ❑Other(specify): City State Zip Code State Where Incorporated GRAND ISLAND NE 68803 NE IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code c;stet- Jean lain Larc�;G Yrz-c:cttekit PO, e_p_A 313 Ever Areeh (- . _ 1 . la t9 aisis- DESCRIPTION OFTHE MOTOR VEHICLES •Attach an additional sheet,it necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, p If Newly Purchased 14 0 0.44.- .2oo7 4 Doi r Seita IH&FA 165",271- 13/.51-56 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑Agricultural/Horticultural [p Educational [A Religious cz Charltade ❑Cemetery as H d ed7 Give detailed description of use,Including an explanation It multiple use classifications exist: p YES ❑NO Tine c:ar Is :4562 -Per erS oral Pi In,STr Visrt.nq tke skCk +aiPie- y, (�ivJ ..(j tk z Ca..,5,is i-.o:1n erf'�-jh f6�'7J Euc�.0 r i s± to' tf.c.-. i n e i r h e n e..5 hp ce +al s °1— J If No.give percentage of exempt use: i ns�};-fn}tens . Per Cl1hr(K C f i,se'e1.. 4 p4rtc i peiti“1 in Li-1 4rgit.t.i Se.r✓ice-sa % -f-ycY YtI.J:OU> e-ct�-c,�.f G'r+ CCa SS ZS •{- rJr b-.te-tl-'.q f�G hcc.�(t OT fr�Se I+1y fequ:rrn=1 c*.Qduectc' r .6v fear, Ske('Ler L eancicj.. : —l'Fanc rot-1 41G,-. .a1C, V Under penalties of law,I declare that I have examined this application and that it Is,to the best of my knowledge and bete(,true,complete,and correct.I also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. sign 7 . , , • ^/ L �....i - . u QCis i^U' IVx ,Nr STe" 1Z `f I 4,01J-- here . :rued Signature Title Date FOR COUNTY TREASURER RE COOMMENDATION + PPROVAL RECEIVE@OMMETS: 16SUrnAAdil-J A cr. it -77' 4'�,e2- + ❑ DISAPPROVAL cite t, 0 DEC 1 0 2015 • it Signature of County Treasurer Date HALL COUNT pv COUN—Y BOARD OF EQUALIZATION USE ONLY 1.6ASU=.EO FW�`CC GRAND ISLAND,NEBRASKA 76.APPROVAL COMMENTS: ❑DISAPPROVAL Aut1r zed Slgna , atZ` e Nebraska Department of Revenue Authorized by Neh Rev.Stat.9977-202(1)M and(d),and 50-3,185,and 80-3,189 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.