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mantung zo kg, <br /> ^—�- Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be bled with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicant's Na a ./ Type of Ownership <br /> Street or Mailing Address/4/6-e-1---'0,-, ���1 Er Nonprofit <br /> County Corporation <br /> � / g/ X It—/. 3=� s i /,4 // ❑Other(specify): <br /> City // S�tat// Zip/Code p State Where Incorporated <br /> // / <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,If necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> 5rd -r 3 S a a i 5 '-rJS Sir z o 2077 Elie/19/7Z? <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational DIRcligious I Qarftable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation If multiple use classifications exist: S ❑NO <br /> .' L O, C /C "Pc 5, Co 11,74.-,C- n- Jr T'y U�O�`,/�S If No,give percentage of exempt use: <br /> -f �S,�{® �%0'/�ejR-sJ Jt+trf'%-S `{.max/.S let.--46> r C¢ xi,yv % <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge and belief,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 property does not discriminate <br /> in membership or empypment based on race,color,or national origin. <br /> sign C -/� r# irlic,n Ar /-/ 9-/here <br /> Authorized <br /> Signature ,.Si e{,�,; �� Ta Dale <br /> r 3�a .,713.7.- VXss ekF / <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> aiPPROVAL RECEIVEDMMENTM: Pia Awe 11-2_07- <br /> ❑DISAPPROVAL JAN 1 9 2018 <br /> i ( , l i t_t r 11 • �- '• a re <br /> HAI 1 m i POW Signature of County Treasurer Date <br /> TREASURERS opeceoUNTY BOARD OF EQUALIZATION USE ONLY <br /> - ORAND BLAND,NCDRA KA <br />' .APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> , 72 <br /> Aut't ad Signal , Date <br /> Nebraska Department of Revenue —/ Authorized by Nab.Rev.Stat.§§77-202(1)(c)and(1),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />