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---z- . Application for Exemption O I. g <br /> F <br /> Nebraska Depanntent of FORM <br /> ___REREVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> VENUE •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Ty at Ownership <br /> CENTRAL NEBRASKA CHILD ADVOCACY CENTER (k(Nonprofit <br /> Street or Other Mailing Address County o 'Corporation <br /> 2335 N WEBB RD HALL <br /> 0 Other(sootily): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Tine Name,Address,City,State,Zip Code <br /> getdive Dice y SLaa-t t r4 Curt( , Lids 4o me le NeeK gel aura /it teem -------- <br /> _ ChAAA. Jerovw c Co 1x1.9 N St • tiwtovol NE (off 1 <br /> vice CAncu 12- kawra %tea.) (7& `Pa a Lo%a. C . Gvaa.-JA �IJL ultra <br /> if L2av�tt Cleo t r 1VG�cy t'4c.6t cm i ND3 iZosewood CL!'_Qra,ad l&lfa gal--J- <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> MotorVehicle Make Model Year BodyTypa Vehicle ID Number Data of Acquisition, <br /> If Newly Purchased <br /> T.C2grt> 2 Do2 TitUS 1$. — inp 33 Y o 2Wt sq 1- 4Jtm zaIl.----- <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exciusiveiy <br /> Li Agricultural/Horticultural 0 Educational 0 Religious L!Chartable ❑Cemetery as in d sated? <br /> Give detailed description of use,including an explanation if multiple use s aassLiticcaattions exist ,,,,,. /��I ,,/ p��Q,�,,. $YES ONO <br /> UYAM d e Od ,j�0 11 4i 0.1cry NGf- sa.r r ic- (� ""4- 'W6sei/' Q it"!o,eve percentage of exempt use: <br /> t o rntth' r fA, CIL /0 CO ups t ( W (t <br />' ,¢.Glued c#, a ,.cats kits „. 1c . We ctiu a. Acen t <br /> Under penalties of law,f declare that I have examined this application and that it is,to the best of my knowledge and baket,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 properly does not discriminate <br /> In membership or employment based on race,color,at national origin.• <br /> sign ` , ,, ec #r`La- Dizdo u- ( I it ill r7 <br /> here kAuthorized Signature Tine Date <br /> FOR COUNTY <br /> TREASURER RECOMMENDATION <br /> PPROV L L� A� " ,x2.0-,x2.0-4--- <br /> NS'`S 7r-aow <br /> RECEIVED <br /> 0 DISAPPR DVAL <br /> NOV 9 2011 ►sl�atyTreasurer ® !—/7 <br /> 4ae,y <br /> HAt I COI INTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> t GRAND ISLAND,NEBRASKA <br /> 14413PROVAL COMMENTS: <br /> o DISAPPROVAL <br /> e , --DD . / �-/e / ."""4 - - l — L ((?-- <br /> zed Signs ore . Date <br /> Nebraska Depareaent of Revenue Authorized by Neb.Rev.Stat.§§77-202(11(o)and(d).and 60-3.185,and 603.139 <br /> 16453-2006 Rev.0-2011 Supersedes 96-253-2003 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />