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at,cg <br /> mitken----z-- Application for Exemption FORM <br /> Nebraska Dapanmen:cf <br /> REVENUE GNUS from Motor VehicleTaxes by Qualifying Nonprofit Organizations 4� <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> :____._---.._.—.________.__.__—_____._._...___---.—___-__-_._.�—_-_._-_—.0.0..0.0—_.--_-__........_ Type of Ownership <br /> Applicants Name Type of Ownership <br /> IGLESIA DE DIOS EBENEZER ]Nonprofit <br /> Street or Other Marling Address County Corporation <br /> 502 E CAPITAL AVE PO BOX 486 HALL L=I Dr t <br /> syedfyz <br /> City _'- State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE _.--0.0.0..0._._—.. <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title I Name.Address.City,State,Zip Code <br /> cE,,�,sL�y,,_ _ _ 0000 __ 1 • 'eaL_!_• ]% • _- 1■ ��._(��_.•-/^_� 1Sis`.,t ¶t .t. Va.�/�rit»N�� <br /> i, e! 1 -., L IA t• % _ s,. y , a_to. I► a ■ ,. ,.'4s <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br /> ! ; Registration Date or <br /> Motor Vehicle Make i Model Year ! Body Type Vehicle ID Number 1 Date of Acquienten, <br /> i it NerwS Purchased _ <br /> I <br /> f I <br /> I -- —=-- I <br /> Exempt Uses of Motor Vehicle: —3 Are the motor vehicles used ea:shyly <br /> 0 AgrculturamorUwitural 0 Educational Rel'glous 0 CharilaGe D Cemetery <br /> as indicated? <br /> Give detailed of u`se,i`n xdarg an expianalwri if mtetiplee�use classifications exist ///�����^ yT YES ❑NO <br /> _k kits ts V V1n W` \1 � AVMs Sock M II No,give percentage of exempt use: <br /> t0 card -€tcb (Xwcc) , D.,\ O \c ci r1 \es c\ arc <br /> '- x sn 'QQokt., <br /> Under penalties of taw.I declare that I have examined this application and that it it to the best of my knowledge and belief,tom.complete,and correct.I <br /> atso declare that I am duly authorized to sign this emotion application.and that the organization owning the above-listed property does not dierrkninate <br /> In membership or employment on race color,or national origin. <br /> Sign C 4-, r ui—.7-17 <br /> here Auth rized Signature Tare Date <br /> L _--- __ FOR COUNTY TREASURER RECOMMENDATION----- -.. — <br /> PROVAI RECEIVE <br /> 0 DISAPPROVAL __-_ -___-_ 0.0.0.0. <br /> - _.-___-__-_.-. <br /> /a-at-/7 <br /> NOV 7 2011 ►Signature ou Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> . HALL'TREASURERS OFFICE <br /> r APPROVAL GRAND ISLAND,NEBRAS4UENTS <br /> 0 DISAPPROVAL <br /> '- --- - -1' <br /> • <br /> cod SIgnat:I.: Date <br /> Nebraska Department a Revenue Authorized by Nab.Rea 5W.§§lb202(1XC)and(di.and 60-3,185.and 613,189 <br /> 9-28+2096 Rex 8-2011 Supersedes 96-2534066 Rev 54009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />