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„ ' eL---e...- Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To he filed wtth your county treasurer. •Read Instructions on reverse side. A licant'ss Name �r � e-.5_ `()(/y' _ �l , `-1�,. �,(1 Type of Ownership t`, ._!-r\t�l t c -nt�T ` reoie OAD aCke, . vci $Nonprofit Street or Other Mailing Address_ �'^ Q County I� I Corporation 1 O o4 cEv u*Y\ 5� Jk r'CGi p 0 13Q)L 'U tO3 RkL J ❑Other(specify): City_.....17c c b --l..a.�l k b Stale p Code State WherelgeoE.__etl CC r� IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code Per Air bOJCI- DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,If necessary. Registration Date or Motor Vehicle Make Model Year BodyType Vehicle ID Number Date of Acquisition, It Newly Purchased Jo:n& Ao14 VAtJ a c.4RDC.Cc1-1ER4a1 as/n5/aotto Exempt Uses of Motor Vehicle: :, Are the motor vehicles used exclusively III Agricultural/Horticultural W Horticultural Educational ❑Religious ❑Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist: Ig YES 0 N Used T«- 9te^k-,tn5 f^1 ani -kaki r5 hams_ or- II t.- Ad- -}Q tN��e C\teA # oc v1i\ II No,give percentage of exempt use: 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 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 E D d s` 7. here onzed Signature Title Date RECEIVEDFor COUNTY TREASURER RECOMMENDATION ��} �f 7 Lyy.AYPRCVAL FEB �• WS COMMENTS: _ ' /T`_ n., Aif,63 ' 1gs30 ❑ DISAPPROVAL Ff B - 5 2016 t HALL COUNTY /_ .—!_.y /Ir. :. '^a` L�ja t..ric ?Irp • TREASURERS OFFICE Signature of County Treasu - gb,' ./ e frRn Q ISLAND,NCf1RADNA roll COUNTY BOARD OF EQUALIZATION USE ONLY ❑APPROVAL COMMENTS: ❑ DISAPPROVAL �/� w • A r'.' ,•Sir-atu 'II Date Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 005,169 98-253-2006 Rev.8-2011 S pemedes 96-2512006 Rev.5-2039 PLEASE RETAIN A COPY FOR YOUR RECORDS.