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Nebraska D^-z 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 /> Applicant's Name Type of Ownership <br /> (511 Pl /-N GAR-; lv T Rh-i /✓ <br /> Street or Other Mailing Address 'l Count Nonprofit <br /> r/ /N(j,3 �l/� Y��� 1 Corporation <br /> 'jja7 N S,I�}Dy EcA/D Rai - Pa x /56� h ❑Other( peci(y) <br /> City State Zip Code State Where Incorporated <br /> C Afi—nq�+ XS•1-n/o /V 5. A2676 2 /V <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name.Address,City,Slate,Zip Code <br /> 5/0 OCR- MMvn-6 -Q r•-.6.4`i c,-, i&eK. . 5-5-. $1i46rea4c.Rits , a. r. Ns 6 sec/ <br /> 11tt nfnvn-6er MveeN aC-A'ft, /7e87 4/ '/ 1V:ARA/PX,ill= t,fffle <br /> <5-e c re-kJ-O-r y km/ lCoeA1er, 5:9.5 (Di llsoa Aug Rill/AS ‘,540..1 _ <br /> r c p-Surer /--1:/ z 4-R�rrt- srache rs , Acs t/�7/ 7/i/LRaJ /Vg — <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Dale of Acquisition, <br /> it Newly Purchased <br /> J-1AuU./214/7P? a ve,6 O f, -IT' iR/4 /dNc&/61y_i 6 Yds7 f—HQ aa/fe <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> El AgriculturatHorticulturai ❑Educational 0 Religious NI Charitable 0 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: MMES 0 NO <br /> Cl}ED r o F L fru tub Rf1-isfR, flc+ 4:cs 4113b <br /> ..y,� ,(,�o�S If No,give percentage of exempt use: <br /> Go GLecllwy LLo"nt2A,y ,-,�a mom, .-4 e? <br /> /A' Cc,L.#'tra-L N`6 <br /> co P' r net- - C>'/-t27. c.a, 'SCf <br /> 3o8 -35'i -o23r <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 /> here ► „ dS( 1 Brs, C J�'1a,d�Sz, t -,19 /6 <br /> Authorized Sig Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION �9s <br /> [ PPROVAL RECEIVEDMMEN S: ��tao �� 't'"T '� �� `��`�� <br /> 0 DISAPPROVAL <br /> JUN 3 0 2016 �al 7___t=,"0 <br /> Signature of aunty Treasurer Date <br /> MALL COUNTY FOR COUN BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> APPROVAL GRAND ISLAND,NEBRASKA <br /> W IV Lry l <br /> ❑DISAPPROVAL el A ��� <br />• .. '}r'-.S1r.f re ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat§§77-202(11(c1 and id).and 60.3.185.and 60-3.189 <br /> 96-253-2006 Reg 8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />