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01/0312018 14:47 3083824033 ff 1 P.0011001 <br /> Application for.Exemption FORM <br /> Nebr�aska/D�eperonent of <br /> REVS I lE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO he filed Mt your County treatreasurer.easure . <br /> •Read ihstrutilons on reverse side. <br /> Mrs Name - Type of Ownership <br /> EVANGELICAL LUTHERAN OSS HASTINGS VILLAGE HOME HEALTH ❑Nonprofit <br /> streelcrOMerMatg Address County Corporation <br /> city State Zp Code StateWhxe Incorporated ❑Other(self* <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> The Name,Address,DIM State,Zip Code <br /> • <br /> • <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •ARadh en additional fleet,I necessary. <br /> Registration Date or <br /> MatorVehlole Make ModelYmr aodyTYps VeMek lO Number Date of ACqulaNion, <br /> if NSW Purchased <br /> • CHEVROLET 2013 IMPALA 2G1W05E36D1100945 1/2017 <br /> • <br /> tempt Uses of Motor Vehicle: Are the motor vehicles used exiMI M1y <br /> ❑AgdwlWngl of ieultural ❑Educational ❑Religious O ctwltab . ❑Cemetery as ind ! <br /> Give deleted description of use,Including an ekpinetion If multiple use dassiGatvons tat OYES ONO <br /> if No give parceatage of exempt use: <br /> 16 <br /> • <br /> Under penalties of law,I daekaethat I have examined this application and dial us,bee best of my wnWledge and ORS,true,complete,and correct I <br /> also declare that I am duty authorized to sign thlprcmptlon appriation,and that organization owneg theSore-listed property does not disalminate <br /> m membsMhlp or employment based on race,cow,or national origin. . • <br /> sign <br /> here /Authorized eignaWra The Data <br /> FOR COUNTYTRE�ASeUREERR�RECOMMENDATION J l <br /> O.kPPROVAL COMMETETS Oe 4/ /7'': .c5 4—77 4.2 r�c_ <br /> ❑DISAPPROVAL. /�' <br /> � aW 11-q-ate f7 <br /> SIgnatura5f Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY - <br /> g PROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> Signature <br /> Nebraska Depart/NW ei Reierue AWpd9d W Nob.n«SOIL fy 77,202(1)(4 Ina(10.and eaa,ree,awl 60000a <br /> e62392o0e Rea 6201 t eILMedes ua-2532008 Re¢64°00 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> • <br />