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AO /7 <br /> mityn---z— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations <br /> •Ta be sled with your county treasurer. 457 <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> CENTER FOR INDEPENDENT LIVING <br /> ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3335 W CAPITAL AVE HALL <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Prl<;Ci?rr " Tk(Y'\ 1�611'1 i n?— U . 1ee4 Irolr-t'11n1N(_ &`t9&9 <br /> L-1 1 Lc EPre idAn+ -4`,e-CL r<-11 t 2,I t a ce � rn :n�irw7� '%9sat <br /> , r <br /> ;At . 10; ,r' ce .re r• Si LJG , 41Jr'r1: &in i _-el i rr. tv` '. <br /> tk'(G ir ( ‘ ..=C r m•oreer 1)Vf^ilG+0; ; 3,s i, i. !--.-tot y1 plvii. , t'[e,mint /0%.15s- <br /> Q,r\r,k i'i s"+4riid-Sr Chr An TLrener, 1.0 IS S Co+ vWCSOJ , Nor t4d)ct*:-.1'Nf bMOt <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary, <br /> Motor Vehicle Make Model Year Body ate of Registration Date or <br /> dYTYPe Vehicle ID Number Date of Purchased <br /> - - - - <br /> If NeRiyPUI'chased <br /> CHEVY IMPALA 2005 4 DOOR SEDAN 2G1WH55K559239446 _ <br /> FORD TAURUS SE 2007 4 DOOR SEDAN 1 FAFP53UX7A162150 <br /> 1 - <br /> Exempt Uses of Motor Vehicle: Are the motor h' <br /> ve Icles used exclusively <br /> ❑Agricultural/Horticultural ,g1 Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,Including an explanation if multiple use classifications exist: IC S'ES ❑NO <br /> Myew, Thv ,. r _.`-_,r>'.r_' `,t', i t _ ._ <br /> it No,give percentage of exempt use: <br /> •t. <br /> t _ <br /> ``):^\I )IYtL?� �{1J°2 .,... j-c-,r <br /> Under penalties of law,I hectare that I have examined this application and that it is,to the best of my knowledge and belief,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> In me n ership or employment based on race,color,or national origin. <br /> sign C .°rumt� GXercrf'i!e ;[i-P(hrr- l i- kY / c <br /> here kit ized Signature T o Date <br /> f FOR COUNTY TREASURER RECOMMENDATION a/ <br /> R PPROVAL RECEIVEVMMENT4-111/C1-1- <br /> 1 <br /> E: / �W .* "Pd—77-c-PrOoP <br /> ❑DISAPPROVAL <br /> NOV 1 4 2016 Signet t /g'--9� /4 <br /> i a of my Treasurer Date <br /> HALL COUNVOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> 1NEMtuRena OrFICt <br /> GRAND ISLAND,NEBRASKA <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> - a <br /> _.r` ...• _,r-_!-d. i Cio 7)7 <br /> uthorized •nature Date <br /> Nebraska Depedment of Revenue Authorized by Neb.Rev.Slat§§77-202(1)(c)and(d).and 60.1165,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96253-2006 Rev.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />