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.ai6 / 7 <br /> Nebraska a„ _ Application for Exemption FORM <br /> REVS''E from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be filed with your county treasurer. <br /> crataggazzimi <br /> •Read instructions on reverse side. <br /> Applicant's Name <br /> Type of Ownership <br /> MOSAIC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2846 OLD FAIR RD HALL ❑Other(specy): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Tale Name,Address,City,State,Zip Code <br /> SEE ATTACHED <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br /> Motor Vehicle Make I Model Yea r <br /> I Body ry!» I Vehicle ID Number Registration Date ate or <br /> Date of Acquisition, <br /> H Newly Purchased <br /> SEE ATTACHED <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational a'lteligious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: BYES ❑NO <br /> Lte�rr.. f(�� d,._d..Q f !6010 <br /> �trdy3�t fo-ito i 6'C' 4:54-6 l-4r� j� °u H No,give percentage of exempt use: <br /> I <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 membership or employment based on race,color,or national origin. <br /> sign <br /> here Authorized ignature Title Date <br /> I FOR COUNTY TREASURER <br /> TRE ASUURE RR RECOMMENDATION i <br /> APPROVAL R C IvEDENTS: A ASj .i/ot /a" A/a � a E <br /> ❑DISAPPROVAL <br /> NOV 1 4 2016 e12- /�- '-, <br /> •oignature of rer Date <br /> ) fall COUFQRCOUNTY BEARD OF EQUALIZATION USE ONLY ' <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NESRASKA <br /> ❑APPROVAL COMMENTS. <br /> ❑DISAPPROVAL <br /> n't'_ :.r., /—/o '/2 <br /> ize.Si.`:urn Mr Date <br /> Nebraska Department of Revenue - Authorized by Neb.Rev.StaL§§77-202(1)(c)and(d),and 60-3.185,and 60-3,189 <br /> 96-2562006 Rev.8-2011 Supersedes 96-253-2006 Rey.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />