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X617 <br /> Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicants Name Type of Ownership <br /> THIRD CITY CHRISTIAN CHURCH Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4100 W 13TH ST HALL <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> 'Mat '11�.il thF� p��_ ►��t���4�i1ri:��7y�Jt�1rn�r�! gr►y'WW.MI 1- ; ; <br /> li� ' IJt�S'nbitli ilar/Llrarrli _ • e I Wr . e i s e <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,if necessary. <br /> Registration Date or <br /> MotorVehlcle Make Model Year Body Typo Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> THOMAS 2001 BUS 4UZAAXBW11CH56883 <br /> Exempt Uses of Molar Vehicle: �T1 Are the motor vehicles used exclusively <br /> ❑AgncuituraVHorticultural ❑Educational 'K Religious ED Charitable ❑Cemetery as indicated? <br /> Give <br /> (Idetailed�ddees�crip�tioon of use,including anneexplanation if multiple use classific Lions eexisjt:�} /L� //,�� /� tvl xES NO <br /> 11W�,a yekl_ 1 -" --t eft'; i 4� ' ` O r�t;i+6,)/M2CP�y/'� If No,give percentage of exempt use: <br /> L a (4.4 1 • 11' mai t c t i l4 c 5-b 7 <br /> rd G h1 C.Kfri sit Ch. roe', <br /> 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 coned.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed properly does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign , S /b) (/-/6 <br /> -I <br /> here Authorized igne ur rule Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> Q�CPPROVAL COMMENTS: '— W s- " 77 <br /> ❑DISAPPROVAL <br /> Signature Treasurer Dale <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1Xc)and(d),and 60-3,185,and 60-3,169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />