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• <br /> ..,,-L • L-- Application for Exemption 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 /> App$glicant's Name cc //�• _�I _ ^ `_lf,�_ ` }''' Type of Ownership <br /> l2 ii f11 ea OT `nrecSe- 1■Sbra'cK t- Lv - rg Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1804 S. A 1 C. P n C3o c 1�3 14P\LL_ ❑Other(specify): . <br /> Ci ( State Zip Code State Where Incorporated <br /> U'«a -�.Slued u¢_ Lo AcE,O .. Qt.- <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br />• Title Name,Address,City,State,Zip Code <br /> Per Aa- A,d <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehkle Make Model Year BodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> en c.; at,(4 - Cram( Carans..n a1144),oeneeniEgaqtsri otla9,1 ltn <br />• <br /> Exempt Uses of Motor Vehicle: r�I Are the motor vehicles used exclusively <br /> ❑AgriculturaUHorticultural Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> VI <br /> Give detailed description of use,including an explanation if multiple use`classifications exist: �..( EYES ❑NO <br /> LlSea "' P � 4� '�.K.Sti hvrnst.--. 'Lt1�. Alto, L°•' If No,give percentage of exempt use: <br /> T t StAtpert o4 CA■ea3r- axXwAte-s f,ly� % 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 belief,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign here \ 'ms's.' - Cam® ab <br /> ,Authori zed Signature <br /> Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> QAPPROVAL RECEIVEF�MMEN . v""7"— 77--07.,,p__, <br /> ❑ DISAPPROVAL <br /> FEB 2 6 2016 � 'LOj� �� <br /> it Signature-of County Treasurer Date <br /> HAl I PM tkl't4OR COUNT,BOARD OF EQUALIZATION USE ONLY <br /> TREASURER$$OFFICE <br /> GRAND ISLAND,'NEBRASKA <br /> APPROVAL COMMbN S: <br /> ❑DISAPPROVAL // /J► • <br /> /,i./�I /. / 411 / <br /> A.1',•Si.'S� ''7 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 /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />