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a0 / 7 <br /> Application for Exemption FORM <br /> Neebbrra�-aska Depanment of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicants Name <br /> Type of Ownership <br /> SISTERS OF CHARITY OF LEAVENWORTH BY SR BARBARA WIESELER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2939 PINNACLE POINTE DR HALL ❑Other(specify): <br /> City State 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 /> ' DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> FORD 2015 FUSION4 DOOR 1FA690HDXF5128387 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ( Religious ❑Charitable ❑Cemete Y as indicated? <br /> .G,iya�detailed description oof use,includin�g�an exidanation if muullttiple use claspifications exit:n t ,,/4 S ONO <br /> lylis PvtPi✓1 '15 bt5f'11 [b Tote- SIjS'1C-�,,/5 o-' C)iNd�.� �I�rPI �41uta+frH <br /> CrA.t`r J —tg�V ref?. n s s UPI dyte(,1 f '( i ma IL Q 8 No,give percentage of exempt use: <br /> I)ea.l+eic ✓e w w l s Q`e�f I . 'f H -Frew f i cat <br /> lfe., 115p47 �a h NJI s 5.4 id t <br /> le fr i i r 41) -P rpie5wSetemmicl <br /> zi4 <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 app9cation,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. , f �� <br /> sign r � G G - �Lf 1, <br /> p !a_'� y� .:4LeL EA I�.azl�u ' <br /> here Authorized Signature i ' 4 , cry , 7 -i„/. Date <br /> l s FOR COUNTY TREASURER RECOMMENDATION <br /> SAPPROVAL COMMENTS: rn1,2't ,leat-it <br /> ' <br /> 4/-51 77”'c?Y <br /> ❑DISAPPROVAL <br /> DEC 6 2016 h .g p!a.902_, /- ..,""-,"7 <br /> Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> MALL COUNTY <br /> TREASURERS OFFICE <br /> ❑APPROVAL GRAND ISLAND,NEBRA <br /> ❑DISAPPROVAL GGOO <br /> / AO <br /> �0 _,, l >�.-i . '_ % /-1n-7/7 <br /> Authorized Sig , Sr Date <br /> Nebreska Depermied of Revenue Authorized by Neb.Rey.Stat.M 11.202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />