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� L Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicants Name - Type of Ownership <br /> 1 !^_•' <br /> .► ' - 0 If 0 .-._i; •I ei / • ' ay, �r Y-�t/1'a— IN1 eSVl— [/ionprolit <br /> Street or Other Mailing Addres County Corporation <br /> I <br /> +J(yJ� Ty,vi +.?�Q•(t[/I�L �t Ve ]�/.Lf Other jsPecifyi. <br /> City <br /> Kite Zip Code Slate Where Incorporated <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address.City.State,Zip Code <br /> 1, <br /> �L .A _ _ _...r I r u' r J ..:0 �.... •'/ 1, J1 •4 I ratl! „1 rim <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Ne y Pur based <br /> EovA Fu4ie.o gag: 4-nezvr FA op ti Dx Es)?7.351 519{i6 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 0 Agricultural/Horticultural ❑Educational ERCIrgious ❑Charitable jJ Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: Li YES O NO <br /> TI- pro i`t( e� used TT.yy'y�7 ,.,/s j5� > O l—T(,(lCU'lyE� If Ne.give percentage of exempt use: <br /> of t F"I f1�1/i w+�n'vi"rrtl Fr7V(!`Yyltl to &W ti�Vr t O ei ✓d 1l t NiS f <br /> eft uat i. ,ri °i- eAcwl cup✓ • <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 exemplion application,and that the organization owning the above-fisted property does not discriminate <br /> in membership or employment based on race.color,or national origin. <br /> 0 <br /> sign �,� I ._ �aatz C� ! l <br /> here '� tu,..�.�. <br /> Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION /�J <br /> APPROVAL RECEIVED COMMENTS: �''""T ."2 " �4'. 77 <br /> 0 DISAPPROVAL JUN 1 7 2016 <br /> �Qj l-07/-lam• <br /> HALL COUNTY (►Signature Treasurer Date <br /> TREASURERS Orrfc.Fr,o COWTY BOARD OF EQUALIZATION USE ONLY <br /> CRP HQ IS AMD,NE <br /> a <br /> yl APPROVAL COMMENTS: <br /> 0 DISAPPROVAL "Irr <br /> •rorize.Sig :cure <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat§§77.202(11(c)and(dl.and 60-3.195-and a&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 />