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a o / 7 <br /> Nebraska Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be tiled whh your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> HEARTLAND LUTHERAN HIGH SCHOOL ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3900 W HUSKER HWY HALL <br /> ❑Other(specify): <br /> City State Zip Code Slate 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 /> --e., -C.rv�cd.c .1/4..\ l s,_rm. 1 )5 d rrc,r G\ .in Co ' r(3 <br /> ?ux,rd Cetr- .r e.k,e4\' -' 3\'Y, ‘..,,Dc-N. 'fY\E-moo<Srnr,.I'n .c \ti\%Ac Y- , C. . fC Ca kk(-`: ai <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make Medal Year I Body Type I Vehicle ID Number Date of Acquisition, <br /> i/Newly Purchased <br /> .1DIrERN PteNAi .- p •- . . . <br /> CHEW 1999 SUBURBAN 3GNEC16R9X6210246 <br /> — <br /> THOMAS 2003 BUS 1T7TR2C2731131634 I, <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural 13,Educational ❑Religious ❑Charitable El Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: sij YES ❑NO <br /> Ut cl..LsC 4c-r-C ,s-13'-.tom C 'r` "^ C J'"1.,_a'Q-r,) "�� d- If No,give percentage of exempt use: <br /> CSc.<-n 7C. — oo\ ,k e\C.,-\2.C` C&Lh1V ; -\-sNe_ . LI1/4-eliL'. COr <br /> Under penalties o f law,l declare that <br /> 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. <br /> sign _ <br /> cinc.■ic• it--/ - 140 <br /> here ,Authorized Signature The Dale <br /> p. FOR COUNTY TREASURER.REECOOM-MENDATION <br /> APPROVAL RECEIVEDCOMMEVTS: - 7" /o"Q�'' N5. 77�O <br /> ❑DISAPPROWL NOV 2 <br /> 8 G',116 <br /> �P /a-GP/‘.uaL' COUNTY ,Signature of Canty Treasurer Date <br /> l TREASURERS OFFIQGR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND i8..ruND,lvtbFtHanM <br /> ['APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> r�.,f_.-..... I ris i_ ./_serf.:,Ara- /O/ f <br /> Aur-thorized Signal W. Date <br /> Nebraska Department R v. 11 Supersedes Aaaiogizad by Ned Raw.Stan-§§7740211)W and Id),anr1863,185,and 603,1 B9 <br /> 96-253-2006 Rev.8-2011 auparsedea 86253200E Rev.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />