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6/ 7 <br /> ma z- Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be Mid with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> NORTHRIDGE ASSEMBLY OF GOD ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3025 INDEPENDENCE AVE HALL <br /> City State ❑Other(specify): <br /> Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City.State,Zip Code <br /> TREA5029,_ ,MARX 5MN)AEC.77 9SO ?ER42(E Kb•Auko24 MEG887ir <br /> Sec ttrWt i 1 i R P 1 is Si. A• au wrier,, ) ..rs .f/E !n S'• <br /> ', i'Pal- MA* OThaBeYi 03 • emob Av£ eee949 251.110D/ N£ Etas <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make Model Year Body Type Date of cnDati n, <br /> dy ype Vehicle ID Number Date of Purchased <br /> if Newly Purchased <br /> FORD 2008 ECONOLINE WAGON 1 FBSS31 L28DB25474 <br /> FORD 1995 E3500 CLUB WAGON 1FBJS31HOSHB19406 <br /> CLASSIC 1995 ENCLOSED TRAILER 10WAAEE215W020985 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturalMorticultural ID Educational t<Religious Ill Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,Including an explanation if multiple use classifications exist tgYES ❑NO <br /> (. % ice ,HESS VEmeLES Rya muwsfox7.0700 of FEapt1 Apr) <br /> If/. OA-6Z 7b A•Nb pstch n. c'NVKC�l ft-f eh7'Eb .(Erin o r No,give percentage of exempt use: <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 /> signs 4Jt 5 . (!2 % sic /S I/-Z(1 <br /> here I Autho'zed Signature Title Date <br /> r� FOR COUNTY TREASURER RECOMMENDATION r7 <br /> E APPROVAL COMMENTS: y$ F. "7! "T�`� <br /> ❑DISAPPROVAL RECEIVED <br /> NOV C U '201.0. Signatu of unty Treasurer Date <br /> FOR COUNTY BOARD OF EQUAUZATION USE ONLY <br /> HALL COUNTY <br /> ❑APPROVAL TREASURERS OFFICEaeMEN—S: <br /> GRAND ISLAND,NEB <br /> ❑DISAPPROVAL ' <br /> viii.=..Aar .0%.0e Act- /-/O /,7 <br /> Authorized -. _'r,- Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-282(1)(c)and(d),and 60-3,185,and 603,189 <br /> 9-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />