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+...-L— _ Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •To be flied with your county treasurer. 457 <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> CENTRAL NEBRASKA HUMANE SOCIETY ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1312 SKY PARK RD HALL n other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br />• <br /> Title Name,Address,City,State,Zip Code <br /> TTes ;3tytt I--Qiso• Rowe 15`-1(e2 tv -ac_•-cc.vS I KetnESAvJ 1.1E lrZg51c <br /> V;(.._E., ,-es;ac_ s f } .X.A1& t-wrStel 1123 W lst 5t Erg.-,C1 Ts\&nd I.I E is ge,3 <br /> 1reasv.).-erl NSWty C1 end-t t9 5 +{-Eh Art oe1v15 NE u <br /> 2D <br /> r <br /> s iEZ,L1;ve -b;ecE4 i alLVtc De 41lac-E) .. I <ifESkk 5 Ls 1(4, Cs cl �sla�d (c Y,� <br /> L NE ! <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear I DodyTYPO Vehicle lD Number. I Date of Acquisition, <br /> ._. ,. , <br /> if Retvvly Purchased <br /> CHEW 2009 EXPRESS VAN 1GCGG925CX91t26172 <br /> DODGE 2001 CARGO VAN .. 2B7HB11X01K529298 <br /> GREAT DANE 2012 SEMI ENCOLSED TRLR- 53BTE1624DA007564 <br /> CHEW 2015 SILVERADO K1500 1GCVKREC5FZ282986 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriadWralMOrticulturel CI Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES ❑NO <br /> Li I -k- "-CU's pc^--4-i tz�i owl i mills eviAct Supplies <br /> (1 If No,give percentage of exempt use: <br /> �t Ofv t'\/Y1-1•5 410-- axe. 51ad.lere cI 4-L et-1/41-rd % <br /> i Vt-\Jv' .4.a 14zu.neAste_Soc_ e cu,1d Ain ne ems„ l <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 lam duly authori.::•to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in mem•: hip or employment bas on race,color,or national origin. <br /> sign , A, 4,, /. as -;Ie-CLL, tVe- i:veilOr Il-VI- 01 <br /> he orized Signature /, Title Date <br /> I FOR COUNTY TREASURER RECOMMENDATION I <br /> �PPROVAL RECEtUED � �B. E <br /> ❑DISAPPROVAL <br /> ��.Qcr -'d <br /> NOV 1 4 2016 Signalnty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OF�F�I(��� ��� <br /> ❑APPROVAL GRAND ISLAND,NEBRASMAEN'S: <br /> ❑DISAPPROVAL <br /> 'T orized Sgnature ...I- Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stal.§§77-202(1)(c)and(dl,and 602,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5.2069 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />