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Nn--z--- Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be Bled with your county treasurer. <br /> J� r � •Read Instructions on reverse//sii�de. / <br /> $1:al' 5 (e - r 4ry.Yeh 'e�-hI /14h 7-�VifC�f-1//C rypeaonprfnip <br /> t eliYj J j�l,/ r.J ✓r 9 C6vt ❑y�Nanprom <br /> Street or Other lMailliin1g Address 1- Coun(t/j - Corporation <br /> l.¢( l /'} C/1 nit c / r t l ❑Other(specify): <br /> City 6/h 011-/ lAh Stat1 c Zip Code D State Where Incorporated <br /> V'" 7 N (Y gg I yAt/1-e6,-�,S k <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,Ciy.State,Zip Code ry <br /> L 5-0 Corrie ReIWS.-ds if At tutnargh d r 6rm '1 /ehJ JJ ba, 3 <br /> 00 Ire. , OL k-ti 4," _ 07 <br /> >=0 L , c t- ' iI 7ff /.1. .r:6 <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 /> It Newly Purchased <br /> U1 F & 200'-7 -}-rot�re Lt Y 19 a 1-6 g 177/15 o 4`d 70 <br /> Exempt Uses of Motor Vehicle: r� Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious .€1 Charitable ❑Cemetery as indicated? <br /> Olva detailed description of use,including an explanation if/multiple use classifications exist: L pt IYES ❑NO <br /> -iil�rI4r 5 k/C.c1 +0 l�1Jf 'n,/ l9d04Y T"0 1 iI.t.Cd✓+li�ri 7 <br /> "l 1,5J I� I ,, L II No,give percentage of exempt use: <br /> CV/Gt ha K 4 00015 '1," J 4 4-tr i S 11 ., % <br /> Under penalties or taw,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-fisted property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign nil/ 6 PC ( i 0/ d7 <br /> here Authorized Signature Tale Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> P4PROVAL RECEIVEDMN e-iv elv / /- <br /> S'S' '17- e" <br /> ❑DISAPPROVAL <br /> JAN 1 9 2Q17 !=!9—ice <br /> ii. e_grhey hate-A.ISignatu o CountyTreasurer Date <br /> YREA S <br /> HAI IRLL COUNTY E OARD OF EQUALIZATION USE ONLY <br /> rR$, <br /> GRAND ISLAND,NEBRASKA <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • thorized Signature ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§I 77-202(1)(c)and Id),and 603,185,and 603.189 <br /> 962532006 Rev.8-2011 Supersedes 98-253-2006 Rev.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />