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wy^.---z— Application for Exemption FORM <br /> Nebraska Department 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 /> \ Applicant's Name Type of Ownership <br /> ‘,..,'\-\ GOOD SAi9A''i T� 506 CTY 6-denNJJ ZYLRiwP EMI 46-#5 Nonprofit <br /> $4tr/eett}or Other Mailing Address [' Cou Corporation <br /> J t 7 c r//�l eEA-2/4'E J T /r k L ❑other(specify): <br /> C Zip Code State Where Incorporated <br /> 6 �%'itl1� zSLg� Air <br /> a863 S©ug ,?fin TR <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> h Title Name,Address,City,State,Zip Code <br /> Qc <br /> i d <br /> L _ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach en additional sheet,IT necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BotlyType Vehicle l0-Number Date of Acquisition, <br /> If Reply Purchased <br /> C c REVRPLE i �+U®2 K�sc a p/z.ka r / G c Ht2ya ik:Esec yf'o/ 20/7 <br /> V Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> v ❑Agricultural/Horticultural ❑Educational ®Religious Pi Charitable ❑Cemetery as indicated? <br /> IQGive detailed description of use,including an explanation if multiple use classifications exist: AYES ❑NO <br /> V <br /> iHis VE11ic(.E /5 cfsIn Fay' mRiiurE.flt9iUC.E lF�ouiu/J nit <br /> r&"ti7Y fickiN6i Up AND i//r!uti/U(r TODD S�,SUPP�/ tS "R f If NO,ghee percentage of exempt use: <br /> Eau/'pity Woow Mfg Ma✓ i.) LA/U9Sc4Pi/JG-, fTC . <br /> w <br /> Under penalties of law,I declare that 1 have examined this application and that it is,to the best of my knowledge and belief,true,complete,and correct I <br /> 9 P <br /> also declare that lam duly authorized to sign this exemption application,and that the organization owning the above-listed nmd <br /> Y P aPl ergs n9 above-sted property does discriminate <br /> in membership ayem t based on race,color,or national origin. <br /> sign , ;// �� rjcec:.pf #M> ( I <br /> here rized S' tore T :de <br /> �/ FOR COUNTY TREASURER RECOMMENDATI ON <br /> ❑APPROVAL rrhktkFNTS: film pap / /U 4.3 tiny? <br /> Deg <br /> R <br /> ❑DISAPPRCYAL RECEIVED <br /> APR 1 1 2017/ :of re p .-,717 , , „ /a•/7 <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> VA PROVAL_ TREASURERS OFFICE MME NTS: <br /> GRAND ISLAND,NEBRASRPe <br /> ❑DISAPPROVAL <br /> t <br /> • thorized ignature mir Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§77-202(1)(c)and(2),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 98-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />