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TO BE FILED WITH Application for Exemption FORM <br /> YOUR COUNTY from Motor Vehicle Taxes <br /> TREASURER by Qualifying Nonprofit Organizations 457 <br /> •Read instructions on reverse side <br /> Applicant's Name {'� �l ` t County Type of Ownership <br /> C�nya-11. 111 1 S tc5 �C lip oP�ta5 (y lL1c 1--k k1✓L RI-1'40W <br /> ofit <br /> Street or Other Mailing Address !� Q r County Number Corporation <br /> 126 4 Safl1 Sk. ,_ P. (1. RX O 103 ❑Other cspecif0 <br /> City ` _ _l State Zip Code State Where Incorporated <br /> (2 rand VS\and 1Ja-- 10 5130 t3 L..- <br /> Identify Officers,Directors,or Partners <br /> Title Name,Address,City,State,Zip Code <br /> Per M4hd-ed <br /> LIST SPECIFIC DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach additional sheet if necessary <br /> Registration Date or Date <br /> Vehicle Make Model Year Body Type Vehicle Identification Number of Acquisition it Newly <br /> Purchased <br /> Fdrci ,gotLn SentxIncIr IcnerL\rsgGJ' 0319th a/Ito/ita <br /> 45 <br /> Nature of Use of Motor Vehicle: Are the motor vehicles used <br /> ❑Agricultural/Horticultural a Educational El Religious ❑Charitbbir, ❑Cemetery exclusively as indicated? <br /> Give detailed desert bon of use,including an explanation if multiple classifications exist: Si YES ❑NO <br /> url� r c � ckt 3 U,� /t A j,(t 1<1 A M r C or 1- ,, s If No,give percentage: % <br /> c .ind of it POr-rt- aC r\ t' ar t✓i-4-, <br /> _ a'�tra , r. �a <br /> Under penalties of law,I declare that I have examined this application and,to the best of my knowledge and belief,it is correct and <br /> complete.I also declare that lam duly authorized to sign this exemption application,and that the organization owning said property does not <br /> discriminate in membership or employment based on race,color,or national origin. <br /> sign '1/�(fJ/(n (7O _� <br /> here ,AUt �tl5gn a Title ° <br /> FOR COUNTY TREASURER'S RECOMMEE�N�D,A,TTIONI'�S <br /> APPROVAL g � ��OMMEN�"S: A —" /°^'�- / -F. fin-a'p <br /> ❑DISAPPROVA_ {� �� �� � <br /> AUG 1 B 2016 �/9-O� <br /> /SSnat( nty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALLLUUN7Y <br /> `1 TREASURERS OFFICE <br /> APPROVAL GRAND ISLAND,NEBRf55&.j5: <br /> ❑DISAPPROVAL 1 / / <br /> dill, ' /% r Clio <br /> ',aced Irma, ger r rar r Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§77-202(1)(c)08.960-3185§60.3189 <br /> 96-253-2006 Rev.5'2009 Supersedes 96-253-2006 Rev.11-2008 <br /> PLEASE MAKE A COPY FOR YOUR RECORDS <br />