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Nebraska ---e__ f Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> ® <br /> •To be filed with your county treasurer. <br /> •Read instruct' ns on reverse side. <br /> Apollo' am <br /> PP TYPO of Nonprofit <br /> . V s win' <br /> I�V 7 J 'r (/"s' NOnprofil <br /> Street or t11 Adtlrey\9.\ C/f,�/� � cf..ntt�'� I ! 'Corporation <br /> (/✓ �-itt. l ()V l (� 1, ❑Other!specifyl: <br /> City 'i y ° - , / Sl�ajte Zip otl-� -f' "J State tamer 1 orated L.2 <br /> IDENTIFY OFFICERS,DIRE TORS.OR PARTNER FTH`NONPROFIT ORGANIZATION <br /> Title Name,Address.City,State,Zip Code <br /> AI 1 i I <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 Date of Acquisition. <br /> if Newly Purchased <br /> IN 1.1 GOia T r o t lee- -CrS SC/ aI)CC ra 7—/6/6 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural p Educational Religious ❑Charitable 111 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist' IVES ❑NO <br /> Wed To arcs kwwr" bt esco - 1*Mr fd C4 rev'S and No.g <br /> If No,give percentage of exempt use <br /> Under penalties of law,I declare that I have examined this application and that d 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 i� '� �r <br /> hereq gIjp� }p/ 1Ay' �(l�n`� /y// ��qJJ/JJ <br /> Authorize Ir . - p/�/��1�' rale V V V s 4\ �`� 1 `. � Dat--e'� �' �/ <br /> FOR COUNTY TREASURER RECOMMENDATION I <br /> V APPROVAo_ RECEIVED COMMENTS: rww Ala 11'e:;10- <br /> ❑DISAPPROVAL <br /> JUL 1 5 2 0 16 / / ._ /.4 , :. I .,. . ,ci :. i_-.. , �.(8210 <br /> S. .ture of Cou y reasurer to <br /> HALL COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY J <br /> GRAND ISLAND,NEBRASKA <br /> CXAPPROVAL COMMENTS: <br /> �❑DISAPPROVAL - <br /> 'ruthoriz-•iig ature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat§§77-202(11(c)and(d),ano 60-3,t85.and 603.'89 <br /> 96-253-2006 Rev.82011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />