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TO BE FILED WITH Application for Exemption FORM <br /> YOUR COUNTY from Motor VehicleTaxes <br /> TREASURER by Qualifying Nonprofit Organizations 457 <br /> *Read instructions on reverse side <br /> Applicant's '--Y CJC /�, � a.a'{ kar- County Type of Ownership <br /> C �� 14 iec5 r�r Q$ �R. , ` Nonprofit <br /> Street or Other Mailing Address Address !� (� 0 �/ atom County Number Corporation <br /> '? o4 S i- Ski. P 0 �OX ❑Other(specify): <br /> City 1 State Z4 Code State Where Incorporated <br /> C'rand -Z\CIAC\ k'�fr Lia%10 l• -...--• <br /> Identity Officers.Directors.or Partners <br /> This _ r Name,Address,City,State,Zip Code <br /> PP..- fF YI] <br /> LIST SPECIFIC DESCRIPTION OFTHE MOTOR VEHICLES <br /> I •Attach additional sheet if necessary <br /> Registration Date or Date <br /> Vehicle Make Model Year Body Type Vehicle Identification Number of Acquisition il Newly <br /> Purchased <br /> hrt1/4#44—atatAtt <br /> Nature of Use of Motor Vehicle: Are the motor vehicles used <br /> ❑Agricultural/Horticultural IV Educational ❑Religious ❑Charitable ❑Cemetery exclusively as indicated? <br /> Give detailed description of use,including an explanation if multiple classifications exist _ _ tg YES ❑NO <br /> �e1 act bC p tr k u' o` up ant Audit hrcv n e GI ion . If No,give percentage: % <br /> P o i. ssd Q.c' ec .r�.jor+ /pct.1ieRA- ac{i v;4tes <br /> lends a.t.A, ti <br /> Under penalties of law,I declare that I have examined this application and,to the best of my knowledge and belief,it is correct and <br /> complete.I also declare that I an duly authorized to sign this exemption application,and that the organization owning said property does not <br /> discriminate in membership or employment based on race,color,or national origin. <br /> sign Q 1u-S A C.yo �o <br /> here Authorized Signature Title Dat <br /> FOR COUNTYTREASSURRER'S RECOMMENDATION <br /> gr4IPPROVAL RECEIVEDOMMENTS. e 'ERV /^-- 4/ 1177 SO2 <br /> ❑DISAPPROW L <br /> FEB 17 2016 Q�q Y2 -i8= �� <br /> It <br /> • Signature of Co my Treasurer Date <br /> kw 1 nem INTMFOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> ) APPROVAL COMMENTS: <br /> ❑DISAPPROVAL _ISAPPROVAL 'AVA O3 <br /> ;Chatted S =ure ■/ ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet§77-202(1 Xc)(44603085§eo-slag <br /> 96-253-2006 Rev.5-2009 Supersedes 96-253306 Rev.11-2008 <br /> PLEASE MAKE A COPY FOR YOUR RECORDS <br />