Laserfiche WebLink
die <br /> Nebraska Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be Died with your county treasurer. <br /> PROPERTY ASSESSMENT •Read instructions on reverse side. <br /> Applicant's Name I Type of Ownership <br /> _J-- nlesi a( ate_ (yts g bet/eZen , Nonproa <br /> Street Other Mailing Address County Corporation <br /> 502 e L-e0 -le1 4vt'. 130Y 1826 - !.J.N/ ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> tall CI 1 Island hk c 6 8 .02, AID <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zi Code <br /> C-I. C ? e Los .-net -kilo 1t1 Lfe.1t It ...sir 'rand is/�jnI N2 6graI <br /> e1.> le . pie'n Qtanznle2 1.211 Laxi� fjjc'e CxeJ Isle 6 3 <br /> &1 Dla, /L �.v ken �Fsco„ Sm.P e Cca I 61 ,, t pa- /�Xfor <br /> /3, 3--5 n� rr� to fe 2- 2S2 P ka, f stye is LS/ u to'cos , <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 /> ohP(fit la 7 007 , (tam i)Licainer 7611//G39x79//6 is/5- /2_ / 3-/6 <br /> Exempt Uses of Motor Vehicle: Are the motor whiles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational I t Religious ❑Charitable ❑Cemetery as indicated? <br /> rated? <br /> Give e4 tailed description of use,including+anl explanation <br /> �it multiple dassillations exist 0YES ONO <br /> -�"v�ls yeti W1t1 Ge V � � -I-I c°✓1-S iba ea,�a /e /'� <br /> 41_ �-c--ro /j 1 // \ If No,give percentage a of exempt use: <br /> _,0 ek l C{•1 ert4 A t'Yi2n (..Jo n.atr, 0. % <br /> J „v <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 ce,color,or national origin. <br /> sign -I---- - 1 - C z, 1, COl - oe/_/7 <br /> here I'AUthorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION Al <br /> ra/ntae. <br /> • <br /> I�'APPROVAL RECEIvEk{.UMMEflTS: ��" " - 5• 7ac7_ <br /> ❑DISAPPROVAL ''1F1f``` uu �p <br /> - <br /> JAN 9 2017 = 1 v1 ` /-/c- / 7 <br /> It Signature of County Treasurer Date <br /> I TALL COUNTY F OR COUN-Y BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> ❑APPROVAL c.OMM1 NTS: <br /> ❑DISAPPROVAL <br /> etc—i.- / a/'%< ---i p e c2),0/4),/ <br /> •rized Signature <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(e)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev 8-2011 Supersedes 96-253-2006 Rev 5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />