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<br /> eiren.----z-- Application for Exemption FORM
<br /> Nebraska Department of
<br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations
<br /> mrsimemneau •To be flied with your county treasurer. 457
<br /> •Read instructions on reverse side.
<br /> Applicants Name Type of Ownership
<br /> CRISIS CENTER INC Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 2251 N WEBB RD PO BOX 5885 HALL
<br /> City State Zip Code State Where Incorporated ❑Other(specify):
<br /> GRAND ISLAND NE 68802 NE
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,State,Tip Code
<br /> _S _71RI'A, .Ir tiro , dOl Al. G r , - ,.y S�'Q GAT lit.i '
<br /> i.rc ,i ,i'_ =1111 t n' , - , ,o i i [r '0 S. an< „Jr.SD - /
<br /> Vern. alyi___n� a of '0 so Ilia r 73,FL i
<br /> l:r:.�%+�.Y.TIZIM,W2„„; a - rareErfa Ve. Cr[orb, . ; , ,-. 0,
<br /> DESCRIPTION OFTHE MOTOR VEHICLES
<br /> •Attach an additional sheet,R necessary.
<br /> Registration Date or
<br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition,
<br /> If Newly Purchased
<br /> CHEW 2001 VENTURE VAN 1GNDX03E410213099
<br /> FORD 2014 FUSION SE 3FA6P0H99ER169634
<br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively
<br /> ❑AgriculturaVHorticultural ❑Educational ❑Religious Charltable ❑Cemetery as indicated?dicated?
<br /> Give
<br /> /qdetailed
<br /> ��descr/,ipttiion�poff�use,including an explanation if(half use classifications exist: r Oa YES ❑NO
<br /> v,Vacr""k-t1 lA 4L used l if (h�p"�y`� ;op-Li-al-7 f , ' if/Noo,,�give percentage of exempt use:
<br /> 4 / f r i i/ r / rI1 ant rt• r Q/LQ I / %li, 1, /f/11 +0 I, /ff fija ' D�'l 4 " ' �L(.11 6-6((.l the 1(Yl •
<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 me r ip or employm based on race,color,or national origin.
<br /> 08— 38a- ga5o
<br /> sign hJetim Ci hve Director- it/ib/it
<br /> here Authorized ignature Title Date
<br /> I Eon COUNTYTREASURER RECOMMENDATION
<br /> E//
<br /> APPROVAL � "t R VEIV 44,--.05-.- 77-` ' `2
<br /> ❑DISAPPROVAL
<br /> NOV 2 B 2010 �� /4P-. 4"-, --
<br /> 0 Signature ty y Treasurer Date
<br /> HAI 1 rni iJI9P COUNTY BOARD OF EQUALIZATION USE ONLY
<br /> TREASURERS OFFICE
<br /> GRAND ISLAND,NEBRASKA
<br /> ❑APPROVAL CUMMEN1s:
<br /> p DISAPPROVAL /
<br /> ,..: .i. .patt& '..cam :"s //o ,/7
<br /> Authorized Signature r Date
<br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.54 77-202(1)(c)and(d).and 60-3,185.and 603,189
<br /> 96-253-2006 Rev.82011 Supersedes 96-253-2006 Rev 5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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