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Ne a,x :a Departmenr�r Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations ��T <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant'. ma i:yp1e'of Ownership <br /> � s'i rip n)-Ds gFje/Je7�"r ,Nonprofit <br /> Stree Other Mailing Address // County ! /e"Corporation <br /> .5 0 2 e C'a Oa ( Ave D 5X Li 1-ICS/l <br /> ! L!Other{spac!fy): <br /> City State Zip Code State Where Incorporated I <br /> ere rid !s-1`." 5 - C8s>p - A <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State Zip Code <br /> ...-._. ._._._._._...._._.....-..._._._....._._._._.__.�.___._. _-_Moto}- <br /> tj9a � _C'arTos �or llo m 4iee + 13.11E-1 eyaiii rst Gram <br /> C ( pP r . „h-r„���a�s®r,a ,Ao / ,13-0 1' p re-r.q; . 4 ®r tr �S AAA, t <br /> _�s r- ...2..-3i� ._ ZIL a _2&?._._ ?all,-9- rs um� <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> MotorVehicie Make Model Year BodyType Vehicle ID Number Date of Acquisition. <br /> a _ ._. _ - if Newly Purchased <br /> ._—.._ Mott--_..r.... _._.__r�..� <br /> ---3.1.V_'e._a_ltd ___ - 2S'b--------TC_Z. _ __Gir..r._.—L01e1KGr543y_.EQ11`12, ------- - ----------- <br /> Exempt Uses of Motor Vehicle: Are the motor mot o r <br /> vehi c les used exc lt <br /> siireiy <br /> as indicted?:Agricutturalriorticu!ivai L Educational !Religleus ❑Charitable a Csmee ry_ <br /> lt detailed description of use.including an explanation if multiple use dassiix lions exist: ^//y'^ t/IYES ❑NO <br /> t,'kt L .'I ,be U sect el -11ahS'f 1eo R 1C 4° � t J�-' <br /> CGi.J Cf� ' ` If No,give percentage of exempt use: <br /> O <br /> (/ <br /> \r° ""it Ica -(-3, <br /> Under penalties Of law,I declare that i have examined this appiir_ation and that a is,to the best of my knowledge and ballet,true,complete,and correct.! <br /> also decie.r s that I am duly aufwdzed to sign this exemption application,and that the organization owning the above-listed properly does not discriminate <br /> ;'merit.. r employment based on .-,color,or national origin. <br /> Sig( , • /544, <br /> T , <br /> „Lc c„,,_here l.-Au!hodzed Signature Tile Dale <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> PPROVAL RECEIVE DMMEN-5:, ,t, ,/11s:c . X9'7—cQ0. <br /> []DISAPPROVAL <br /> DEC 1 5 2016 a-ate/� <br /> Signature of County Treasurer Date <br /> HALL COUNornAE T' O3p COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND,NEBRASKA <br /> [1 APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> thorizad ignatu;"--' Date <br /> Nebraska Depwbnent at Revenue Aothodzed by Neb.Rev.Shat.§§?7-202(1 AC)and id),and 50.3.135.and 604.1.S2 <br /> 860253.2OO6 Rev.11-201:Supersedes 9E 4.53-2005 new 5.2!:00 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />