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9Qi7 <br /> 'dz Application for Exemption FORM <br /> Nebraska Department a <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations 457 <br /> •To be Bled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> MINISTERIO DIOS ESAMOR ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 423 W THIRD ST HALL ❑Other(specify): <br /> City State Zip Code Stale Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> IRES1DET 54svro5 R. OROONEZ / 0 I. a5 Iny a S FYI <br /> one pS Ton tiaN 1■1- f65g So • <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year I Body Type + Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> BUICK 1995 LESABRE 1G4HP52L25H407272 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricuiuraforacutturai ❑Educational %Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation <br /> j if multiple use classifications exist: J` i [BYES ❑NO <br /> 10 O v R S EE TOE- <br /> 'E- C-UuR t_� 5 N1`r ti s Icy If No,give percentage of exempt use: <br /> I kt2= BP4SCV4- <br /> Under penalties of law,I declare • •:ve 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 -•n this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in m�44 ip ore,xt.-• ace,color,or national origin. <br /> sign r g% firs a0J• �QS-0s . /A/20116, <br /> here Actg.-zed Signature T e Date <br /> I FOR COUNTY TREASURER RECOMMENDATION I <br /> APPROVAL �.�r�l i.III-OMMENT6: •&-""l y 0C'/v /!/, i5. 5 77- 90. <br /> ❑DISAPPROVAL( / <br /> DEC 3 0 2016 W 7--3 11.7- <br /> i'Signature of nty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> l-f rt 'ouNTY <br /> TREASURERS OFFICE <br /> ❑APPROVAL GRAND ISLAND,NEBII `v 1 : <br /> ❑DISAPPROVAL <br /> _.,, • !?.r I&___. , J/0_/7 <br /> • thorized Dana. ?ir Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 603,185,and 60-3,189 <br /> 96253-2006 Rev.8-201 t Supersedes 96-2532006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />