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TO BE FILED WITH Exemption Application FORM <br /> YOUR for Tax Exemption on Real and Personal Property by Qualifying Organizations C <br /> COUNTY ASSESSOR Read instructions on reverse side. 45 <br /> lFailure to properly complete or file this application In a timely manner shall result in a disapproval of the exemption. <br /> Name of Organization f (� County County No. Type of Ownership <br /> (4nnrneL.�.{s/emcL.Iodic#21 1&r/er/Ka/o�er s"9G Act /4 /7 or Nonprofit Corporation <br /> Street or Other Mailing Address State Where Incorporated ❑ Other(Specify) <br /> /10 Box /03 /tie 6rc,.rk0. <br /> City State Zp Code Actual Value Parcel or Location ID Number <br /> 6.-4g4. d'"s%and sf/E 601/232. -"e2, 3 r7. ou V000 9Yz„0 n <br /> Legal description of real property and general description of all tangible personal property,except licensed motor vehicles: L 4.mhe<-F f set eAa Acts_ <br /> 7+0 7�ie C;fy 0 7 Sek,ndil%.rcf L,-1., /2. b /3 4/k Z , d23— N. /JAde Ate. <br /> Title of Officers, <br /> (NName Directors,or Partners Address,City,State,Zip Code <br /> ,lctrrr4 S ctctc%eri5. /�/`encttrilt /(7ol F /7 act f1r.(.-orcy NF (o /ce <br /> '%acta Dvorak r . '2, _ . / . re. , . _ . Net ,ce <br /> /!'like Ale/So., Se tee Yic,/ Alem Mexico Aw G.t ..d i ka4 Aid 6NO3 <br /> _,A'Vet C3 `(on.A or 2aet jcr^ASkten4 /QTY £er:Gla.t Ave. ro( 4CL .1J/crn6fr An, 0_, <br /> Property described above is used in the following exempt category(please mark the applicable boxes): <br /> ❑ Agricultural/Horticultural Society' ❑ Educational ❑ Religious ® Charitable ❑ Cemetery <br /> Give a detailed description of the use of the property: e - ,rL Ac// -Y-a.' _ -,.r V/' _ i a Na' A A ' <br /> P<';m ad,; I 4r- /a die rrreehi./I, . ce,IJin, s«a —For f,/ 14fltersaf-S; <br /> Jet ,?/ached. "err 4 na,/ eflroper-lye. <br /> 'AgriculturaVHorticultural Society does not need to complete the following questions. <br /> Is all of the property used exclusively as described above? NI YES ❑NO <br /> Is a portion of the property used for the sale of alcoholic beverages? ❑YES tRj NO If Yes,state the number of hours per week <br /> Is the property owned or used by an organization which discriminates in <br /> membership or employment based on race,color,or national origin? ❑YES ®NO <br /> Under penalties of law,I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and <br /> complete.I also declare that I am duly authorized to sign this exemption application. <br /> sign oif----- fan den 4- l2A06, <br /> here Author' ignature Title Date <br /> FOR COUNTY ASSESSOR'S RECOMMENDATION <br /> )I APPROVAL COMMENTS: v. • .ae ■ <br /> L' APPROVAL OF A PORTION (n� �`T <br /> ❑ DISAPPROVAL a Ca‘ ,v.-0 \ r G`iva w.' ."T. — it 1."' C F <br /> Signature of nt Assessor Date <br /> FOR COUNTY BOARD EQUALIZATION USE ONLY <br /> I declare that,to the best of my knowledge and belief,the determination hereby made by the County Board of Equalization is correct pursuant <br /> to the laws of the State of Nebraska. <br /> W APPROVED COMMENTS: <br /> ❑ APPROVAL OF A PORTION <br /> ❑ DISAPPROVED i _ .��i f/�L " �_/ <br /> r)-c-_P/:09017 <br /> Signature o ounty Board Tom':r _. Date <br /> Nebraska Department of Revenue - Authorized by Neb.Rev.Stat.$77-202.01 <br /> 96-135-1999 Rev.7-2010 Supersedes 96-135-1999 Rev.-11-200B <br /> PLEASE MAKE A COPY FOR YOUR RECORDS DEC 1 9 2016 <br />