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690 / 7 <br /> edam_ <br /> Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> Ensigsnal •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> HALL COUNTY C/O SENIOR CITIZENS INDUSTRIES INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E THIRD ST HALL ❑Other(specify): <br /> City State Zip Code Slate Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> "SFF ATT!LMIIPTyrr <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Motor Vehicle Make I Model Year g Date of Acquisition, <br /> 11 n, <br /> odyrype Vehicle ID Number Date of Purchased <br /> N Newly Purehasetl <br /> SEE ATTACHED LIST <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgricuhuralHorticultural ❑Educational ❑Religious 1 Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,,innclluding an explanation h multiple use classifications exi-Co- DO/ES ❑NO <br /> -These Veb4(e3 C� uSOF.4 On1 " ` hJNNoo,give percentage of exempt use: <br /> ,VAA,b1I c k k fan$r>rir on. <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 properly does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign s ttko t_I3)-ra,b,r..lrory itizz1ito <br /> here ,Author' Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> RECEIVEDCOMM= TS: el""_�," �e _/ 'l�� �7��t� <br /> PROVAL <br /> ❑DISAPPR• AL <br /> NOV z s ?") s <br /> tr°e /a-4ViCr—,& <br /> Signature Treasurer Dale <br /> 'TREASURERS Ora y'R COU TY BOARD OF EQUALIZATION USE ONLY <br /> ma. - • '• '! ) 1 " . KA <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> thorized ignature Or Date <br /> Nebraska Department of Revenue Authodzed Neb.Rev.Stat. 77-202(1)(c)anti and <br /> by 44 Idl. 801,185 and 60.3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 9:253-2008 Hev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />