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96 g <br /> isten.„--e_ Application for Exemption FORM <br /> N <br /> 0003W/1011;ske 0003W/1011;of <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> ---___—__—_.__ •aead instructions on reverse aide. <br /> Applicant's Name Type of Ownership <br /> MID NEBRASKA INDIVIDUAL SERVICES Nonprotd <br /> Street or Other Mailing Address i County Corporation <br /> 2536 CARLETON AVE HALL <br /> _...1 ❑Other <br /> City --_ Spate Zp Code —_—. I State Where Incorporated lsPaNYS' <br /> GRAND ISLAND NE 68803 i NE ! _.___._.__.._._._.. <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tiede p !Name Address.City,State,Zip Cods V ` �/ <br /> . 1.A.3i hook_...---.----LZ'Y11 kO BLS ('i i hh .rS IG.._.r.i-$.&Q`.4---------------- <br /> - t ce.�srincaN..._-._'�a.�e,.Mas.,4i. 10 St.Prati. Q ni-. 1 f hnr1 ._k. _._l10.8�7..2_.._ <br /> Sec /treasurer 1 AlUeY. C ei-a�t 2019 k S— Or NW. tRR6. <br /> C-F0 i'1li cat CatroheU 2.1e hl "nen tone"new ` kla.rh'nas Mr: 48701 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet It necessary. or <br /> Motor Vehicle Make I Model Year r Body Type I Vehicle ID Number 1 Date of Acquisition, <br /> I i I <br /> ---5gC._ st{a-e, .— — — — — — <br /> i <br /> I I <br /> I i <br /> i <br /> , --- --- ——'--------- i <br /> Exempt Uses of MotaVehicle: :-� Are the motor vehicles used exclusively <br /> 0 Agrkxdhnat lortiwburai 0 Educational j_,f he gipuz 1p Charitable ❑Cemetery <br /> as indicated? <br /> Yx <br /> Clive detailed description of use,including an explanation it mw+iple use classifications exist RYES `i NO <br /> Transvl,ck dekvQiorank-all 9 disa ted <br /> l 0 No,gva percentage of axerrmt moo: <br /> %MIiV;La\s arA PCONi� sex-vi ces I k <br /> hoc emelcyme..ri-• i <br /> 1 <br /> I <br /> 1 <br /> 1 <br /> Under penalties of law,I declare that I have examined this application and that it ls,to the best of my knowledge and belief,true,wlrgrlete,and correct f <br /> also declare that I am duly authorized to sign this exemption application.and that the organization owning the above-Rated property does not discriminate <br /> in membership or employment based on race,color,or national origin. n �) <br /> X Stan s&t 1... aLa,4A1u<tl &ea0 ttr�Trr 1ui/i7 <br /> - ere mio ._-soars ' The Date <br /> FOR COUNTYTREASURER RECOMMENDATION —I <br /> i PPROVAL RECEIVErmE"T3: / /22.4- y• • - #��'.9c>.2-- <br /> fl DISAPPROVAL __—_..-' <br /> NOV 1 5 2017 /4 -..9,--/7 <br /> Signature ou Treasurer Date <br /> U <br /> FOR COUNTS BOARD OF EQUALIZATION USE ONLY <br /> ,,,,..''��__.—_.—.—_._._._ EA <br /> TREASURERS OFFICE <br /> iVrt•,PPROVAL GRAND ISLAND,NEBRe804047 <br /> 9 DISAPPROVAL <br /> e OP /A i / -L-`` <br /> w) <br /> 1._ d Signature <br /> SSignature <br /> ir <br /> Nebraska Drearlmem of Revenue N,ihcrized by Neb.Rev.Slat.§§77-202f11{cl and(9).era 603,185.and se-S,tag <br /> 96.2532006 Rev.8-2011 Sunemedes A6.213.2006 Rev 54009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />