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qtpl-----z— Application for Exemption �C I ( 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 /> CENTER FOR INDEPENDENT LIVING ®Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 3335 W CAPITAL AVE HALL
<br /> • ❑Other(specify):
<br /> City State Zip Code State Where Incorporated
<br /> GRAND ISLAND NE 68803 NE
<br /> -
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,Stale,Zip Code
<br /> Pres;elanY' .1..-in Kolb I Lb ' G' SL. Crania'n, oe (o8!31 _
<br /> 11;tr -Pro:;rl cot- -P41(..61,i1 3i9 x1. ffi;n44n ride. ttlindtin o.LE Ic,y 6.;5`r
<br /> Be-,..),-r.rQkgry in;-1( h":"(1:4;11 N)L1( 4cZ -l-14mP ..(1-
<br /> `,t I At.Rc.x 37 .StjcniS bf l ra, 41 lk;KiFb
<br /> 8 e rA „01 b rnS c r 01--)r;5 -/fun Pr 4-/.5 ) (['.I-Lr+tl,Cri -t . J14.6 A al.ic, U E / (Ir 4 io 1
<br /> Board P 'e,n r- R16..tkreen .hinCan 535 F • vl(;Lary 11Je , -Fr-Frncaff rje ee (`:S)5
<br /> DESCRIPTION OFTHE MOTOR VEHICLES
<br /> *Attach an additional sheet,it necessary.
<br /> Registration Date or
<br /> Motor Vehicle Make Model Year Body Type Vehicle!D Number Date of Acquisition,
<br /> If Newly Purchased
<br /> (' hciy �rn�lc- L5 ,. / - Ll- cky�r ,€Aan =Ciu111551C55g23`LiI4 ;n 1,/iS
<br /> - r4 /TC-t us S r E9et.°7 i-4' hmr 5r An 14:111 rp s3 u-X r la it, I'i) /l
<br /> Exempt Uses of MotorVehicle: Are the motor vehicles used exclusively
<br /> i ❑Agricultural/Horticultural [Educational ❑Religious ❑Charitable ❑Cemetery as indicated?
<br /> Give detailed description of use,including an explanation if multiple use classifications exist: + YES ❑NO
<br /> Ili L,- I (L 7i'' 11(7 that "pt-L U,,el(6 CL L'/L is.4-1 4 3-� If No,give percentage of exempt use:
<br /> 1 ;-1h Sic;I,; I; can f_ q•ci i • i ;ec i 6, r 1n . . t)€tr hones 6, nit
<br /> oejnnt Uri is:E'.r.; .
<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 t am duly authorized to sign this exemption application,and that the organization awning the above-listed properly does not discriminate
<br /> in membership or employment based on race,color,or national origin.
<br /> sign o ��,` aiyL2 cghc IL!-;tn Are( tor i 1 - t C -- ;7o/ 5-
<br /> here I Au
<br /> ized Signature Title Date
<br /> E ¢ FOR COUNTY TREASURER RECOMMENDATION
<br /> DAPPROVAL RECEIVED COMMENTS: 01/Cl A-t- h� // c e
<br /> t La JQ any-lc\
<br /> DISAPPROVAL
<br /> /8-i. -ice
<br /> it Signature of County Treasurer Date
<br /> TRC.H.SdALL RC COUR3NTY c tt: FOR COUNTY BOARD OF EQUALIZATION USE ONLY I
<br /> '0 APPROVAL ISLAND, NEBRASKA
<br /> g0 APPROVAL COMMENTS:
<br /> '❑`DISAPPROVAL �r
<br /> //. ,7 ��,,,, ��ay«�
<br /> Au orized. Ign. ure r Date
<br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,165,and 60-3,189
<br /> 96253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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