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— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •Read instructions ctionu county <br /> sson reverse side. <br /> rer. <br /> Ap Iicants Name 1 ('�('`� ` \' Type of Ownership <br /> (� I,<1t l` T dls_skCtes 111 Rz oto4GC �..�c�a_ .Irc []4nprofit <br /> Street or Other Mailing Address 1� Si) QI County Corporation Corporation <br /> 1 go 4 J• �i_NJ VJ-' 4 0 l oi, , 4,3 L t k-1` ❑Other(specify): <br /> City Q 1. �51a,a 0€_.State Code State Where Incorporated <br /> (` IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Par /\A-41N-chei <br /> I 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 Date of Acquisition, <br /> if Newly Purchased <br /> F'o(23") ,005 F'uctct4 ybR SE 3c'1404)1}9tFka5 81 --Vt ./► , <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural �J Educational ❑Religious ❑Charitable ❑Cemetery as�n,diica indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: I�}YES ❑NO <br /> 4sea Vac picktnq f..pac4Ao G. ker n.,e c1ter \ *. k\s0 11_s sk T <br /> `J 1 If No,give percentage of exempt use: <br /> ;r 5f.ppect ac dter`k- aa..% ".A•te6 cand_Arn�t--et.c • <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 fLokig ,C 6 On, 1fi9ft (0 <br /> here Authoriz ��Si__g��lu``e Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> RECOMMENDATIO N <br /> Et/APPROVAL RECEIVED � Iige4 4//eis d <br /> ; sr 77 7®ca <br /> ❑DISAPPROVAL JUL 1 9 2016 yg __ fj , <br /> Signs County Treasurer Date <br /> HALL COUNTY' <br /> TREASURERS OFFIdROR COL NTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND rSLRND,re bKAbIA <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> /Authorized Signature Date <br /> Nebraska Dominant of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,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 />