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NVsaksDrcf Application for Exemption FORM <br /> RE VENUE front Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> 57 <br /> •TO be tiled with your county treasurer. <br /> mnianntiami •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Tehama Shrine I Central NE Shrine Club RI,Nonprofit <br /> Street or Other Magian Address County C:orpo aeon <br /> 5578 S Engleman Rd P.O,Be%`i-E Hall r- <br /> ------------------------------------"---------`- ---------------------------------------------*---------------------._` _ LJ Ot ei Ispetity7. <br /> Cig State lip Cnda Slate Where IncorpnreMd <br /> Grand Island NE 68803'&- NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tale Name;Add:ass.City,Sam,2p Code • <br /> I Ron Murphy-President 2309 E Stolley Park Rd Grand Island,NE 68801 <br /> Bid Carson-Treasurer 5575 S Engleman Rd Grand Island,NE 68803 <br /> I DESCRIPTION OF THE 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 /> Dodge Ram 2002 Pickup ; 1D7HA18NX25571594 <br /> I SNBD 2010 ' Trailer 5NHUSN223AN069814 <br /> IWehaul 2000 1 Trailer 4X4TSE029YN053286 <br /> i <br />• L.__...-._._._._._._.-_-.._._._._._._._.-_-.._.—._._._.__-..-._.--._._.h-._.—._.__._._.___.__.______._._.___..-._ .._.___ <br /> Exempt Uses N Motor Vehicle: Are the motor vehicles used exclusively <br /> E AgriculturalMarti!ultural [_j Educational [Religious J Charitable as ind6.ated% <br /> -;Cemetery <br /> Give detailed description or use,including an explanation it muaiple use classifications exist "l YES "NO <br /> Used to pull trailer with go carts to promote Shriners Hospital for Children <br /> it No,give percentage M exempt use' <br /> Under penalties Cif taw.I declare that I have examined this application and that it is.to the best of my know:edge and belief,true.oorpiete,and correct.I <br /> also declare that 1 ern duly authorized to sign this exemption application.and that the organization awning the above-ested property does not discriminate <br /> in rnemershhip or employment based on race,color,Or national origin. <br /> sign & ( .�v )< l- /- e >4.,/92-t -ao&6 <br /> Athorize <br /> Tine Date <br /> i FOR COUNTYTREASURER RECOMMENDATION <br /> L <br /> ricIPPROVAL COMMENTS: "-I� "-% _ / L.4v . .51.Si 77 <br /> DISAPPROVAL <br /> � �� _� 7 <br /> It Signatu, o C.'pry Treasurer Date <br /> I FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> 0 APPROVAL COMMENTS: <br /> []DISAPPROVAL <br /> their:zed tome!n l. Date <br /> Nebraaxa napenment of Revenue Auaerized tp Neb.Aev.Slat 3f'?-wit AN and(d).and 6O-3,,e5.and 60-3.189 <br /> 253-20. Rea.8-201 I Supersedes Cis-253.2005 Rev 5'2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />