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eret--,_ Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •Read instructions on reverse side. lfi�,dl,�t's Name ///7� IfR 1' (/�"1+ //� (/'/. -{/-J,(1q �///'{�� y/rte.¢ Type of Ownership! s N .--M(J N N l ,�' �iC�l l cj f /10/ e.. r . } /s y lyl Nonprofit p Street or Other Mailing Address County H. i ` 7�1 Corporation 1c200 fr y A Ue . ! // - 4- ❑Other(specify): City TT State Zip Code Stale Where Incorporated C-Slraffielli i Gbrro NE- 6V303 4/ IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code � ..i o I } b i i - ill ' rl� — & I"S. p DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,if necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, it Newly Purchased • eh ,urnle>- 0/0/6- S�412ar�rn SDV 1.64.1° 4EC,q,p3aic77 '3-24-16 Exempt Uses of Motor Vehicle: //��, Are the motor vehicles used exclusively ❑AgricuhuraUHoniculiural D5I 87ucational ❑Religious ❑Charitable ❑Cemetery as indicated? P ('Give detailed description of use,including an explanation If multiple use classifications exist • S ❑NO U .. I. i n_ ks a r o5 II No,give percentage of exempt use: C..{lL.l_X_J7►'®'f-A^ (( � ff /,_'`(-Ii�l� ✓Gf/�f Zh� o sc-4o0 ( ac1i u h t, 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 also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. sign J 'a''1� ��-- lcrV VI k(1.-161 ?-16 °.201,6 here , mhod,fill igna,ure Title Date FOR COUNTY TREASURER RECOMMENDATION 5^ �PROVAL RECEIVED COMM ENTS: •`�S- Ot �a• �' #fl �� ❑DISAPPROVAL SEP 1 6 2016 � O®•a..1e. 9-!G/A •Signature of County Treasurer Date HALL COUN ty FQR COUt4TY BOARD OF EQUALIZATION USE ONLY T°E'\SU°FPS ' ' GRAND ISLAND,_NEBRASKA APPROVAL COMMENTS: ❑DISAPPROVAL i A / /17204, Au, red ig r . O w� Date Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,169 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.