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� / 7 <br /> N eke .----z — Application for Exemption FORM • <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •R d ntrwts rees treasurer. 457 Instructions onrevre <br /> Applicant's Name Type of Ownership <br /> CENTRAL NEBRASKA CHILD ADVOCACY CENTER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2335 N WEBB RD 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 /> FXPCIAj—(VP Di rent()r Situ-con uAa%Jir-Q 1(33'35 kJ Lui th.- (trard Is) , kit CQKs <br /> i DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,It necessary. <br /> Registration Date or <br /> motor Vehicle Make Model Year Body Type ' Vehicle 10 Number Date of Acquisition, <br /> If Newly Purchased <br /> FORD 2002 FOCUS 1 FAFP33P02W198469 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious 2 Charitable ❑Cemetery as indicated? <br /> 1Givvee detailed description C01 use,including an explanation If multiple use ycrlas-siifiiccations exist: .rtn myth <br /> `A YES 0 NO <br /> Vc tkla tS idea i6Y twt!S Y c&j1(,•1, lY' o v'` m"_"h If No.give Percentage of exempt use: <br /> CLIcG n ine-tir- cisc�.tss 'f eases . <br /> 1J �� 'IS as S 'Asa �fp( Qyk e tr n, s. <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 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 membership or employment based on race.color,or national origin. .714 0e). 5 i S—7p <br /> sig n '4p �f1r . , Mahvej) % ✓ 1l/v /acu o <br /> her kit .rized Signature - 0 The Date <br /> 1 FOR COUNTY TREASURER RECOMMENDATION I <br /> �Z7 Q <br /> 14.105PROVAL COMMENTS: /--ll cs 4OcQ <br /> ❑DISAPPROVAL <br /> d A -.4f-z‘ <br /> /Signature d C3unty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL J <br /> w—%/t!. i ..4,d( :.t, / / /G i7' <br /> • horized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§77-202(1)1c)and(d1,and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />