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a Application for Exemption FORM <br /> -:braska 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 /> Applican' Name ^ Type of Ownership <br /> IQn � l , on prof it <br /> Street or Other Mailing Address\vA I R r� Countyt ` - Corporation <br /> I R 3 LI S 4-. - t-a\` ❑Other(specity): <br /> City›, State Zip Code State Where Incorporated <br /> l7(Y--Va 'tcy1/4.01/441 A. 'RP: 101/0 ( R E .. <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Corps u r Y i o.Nnittay 3S cat, b a <br /> r M C b — vorr A-nn ♦^ - Y 1*Lc �v - -1. ....0 y� ce4 3 <br /> u:5oy <br /> sr A- .k.J/ <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 Purchas-d <br /> ar r ' runs; 35a a—n :ZX • =miF•K 77A g-..).- G <br /> ot • <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> El Agricultural/Horticultural ❑Educational SeReligious litCharitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ^V rck +'ES ❑NO <br /> P' c K. es• Z \ ' onerS 01--. Q \C+-1015" 4.--r Cknsi+ud <br /> If No,give percentage of exempt use: <br />• c0L 97.-eglosg ' 0-w.pi <br /> Und- •e nalties of law,I d- r - have 'ned this application and that it is,to the best of my knowledge and belief,true,complete,and correct.I <br /> al •declare that I am d • autho - -*-n this a mp[ion application,and that the organization owning the above-listed property does not discriminate <br /> in embership or emi oyment b race,cola or national origin. <br /> sign � Cap ocCu r- 8l'il/b <br /> here Authorized Sig • ure MA Q0.`y Title 3 O 390— Lco R Dale <br />• <br /> FOR`COUNT TREASURER RECOM ENDATION ii c)0 <br /> ��' 4/, 5,S # 7'!xoa, <br /> �APPRDVAL RECEIVED EOMMCNTS• �^' <br /> ❑DISAPPRO/AL <br /> AUG8 2016 /Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE <br /> APPROVAL GRAND ISLAND,NEBRASIMOMM:NTS: <br /> ❑DISAPPROVAL I - / '- <br /> ��it%�f" i .; ao`i6 <br /> ,w orized `7-tu ,l e. Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§17-202(1)(c)and Idl,and 603,185,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 />