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•dam— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> comEnnaga •Read Instructions on reverse side. <br /> Appltavnt ss Name /� //�� ,g --'r'' �l ,./yl Type of Ownership <br /> 1 W(�f'r DC G{C.LY\d LSIa✓ oq Nonprofit <br /> Street or Other Mailing Address /� y�7> �/%/ County E/ / Corporation <br /> gl k �i , Co ark°✓ 61 12 e . I ❑Other(specify): <br /> City � State Zip Coe State Where Incorporated <br /> ai.d la,K3 ►vk (OR go ) Ale <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> gate a-cadA a t jt sl <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 <br /> N wly P rchased <br /> FOY-OC 69-t1. Sport v j rig<nmxnKA-c79`5 �i19ke./(a <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural -p•Educational ❑Religious ig Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classif' lons exist: a YES ❑NO <br /> 1 • -1lra�,5 QOINO-fizsn op CiAl LS)- n oh:oni y'100( O t r' <br /> If No,give percentage of exempt use: <br /> 0,44er 30moot rte' Y % <br /> 2 i e e ochoo( <br /> F 601-acid -6-e(el -11-)/6_,_-3. u rn inner - ie I d -ir eS ah_ct oci-r v <br /> 4. Fib u s t1e5 e cni GGu ldca r arid ko <br /> Under penal es of law,I ec re that I have examined this application and that it is,to the best of my know belief,true,complete,and correct.I <br /> also declare that lam 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 /> S �� &a .L_ : 4eeii.6l�sv kv- is 1 <br /> here Aol 'in .. Signature a S' Tift <br /> Data <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> �APPROVA �'r�kd6�FNTS: A`"'—"'"7— f "" 41:95— 77- •Q,0,7 <br /> ❑DISAPPROVAL RECEIVED <br /> OCT 1 1 2016 • Signature of County Tf�r Date <br /> FOR COL NTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> a74 PPROVA- GRAND IISLANDS EB AASSI OMMENTS: <br /> ❑DISAPPROVAL 1 <br /> . <br /> Atli rss -F- r,' Date -(J <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.ss 77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-2532006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />