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id"---z— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicant's Name a `1 ( U tit; C Type of Ownership <br /> 1` .LN 1\.)e..60-04 e..60-04 L\.a- 0 L i0�C ( V a, 0 G cC3 (}Nonprofit <br /> Street or Other Mailing Address ,,J_ County Pot_ ( 7 COrporalion <br /> etr.3G `rit ri 66rs Ate- P 1 ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> am— 13 c“.•■� td £ G 8 8 d 3 N 5 <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code t� //......// <br /> CAA*1rvnaA jean to :A PO nx 134 ( i4�oA -(it CnaC <br /> V,ce- (%J(?rmax ,D0.Ut 041 t- 14a ST Pis f&( 44 sf L;.ar N t 68t/2-- <br /> Sec7Treoa5 R(kn Cc a-K •Zo/7 K \ Qcd .- f. 4 S i C z_ <br /> C. Ea Ora-nr (.s.atp (loci 1 2 I AV Demres- 1b3--Any- . .) C 681 al. <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 /> Hs` R t>»g> - az6l g *fro` CekEYs f 7tyrc (8 8r ) 1 / 7 /r <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural ❑Educational ❑Religious R Charitable ❑Cemetery as indicated? <br /> Give detailed description//of use,including an explanation if multiple use classifications exist: [ -YES ❑NO <br /> f�P6 If No,give percentage of exempt use: <br /> Yo)diJpcstuadS 11 5a -atc,c__ % <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 lam duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> h <br /> sign Auttrodzed Signature `� Title �- - Date' / !8 <br /> (l� FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVE EDMMENn: P1 A. (HISS' {�J 1— oa. <br /> ❑DISAPPROVAL <br /> JAN 1 8 2018 atat�'Yt, <br /> .!r' Leo i it. i. /g//8 <br /> /Signature of County Treasurer Date <br /> TRFASI I <br /> MALI RFRS COOrlO 1'Y__COUNTY BOARD OF EQUALIZATION USE ONLY <br /> _y GRAND ISLAND,NEBRASKA <br /> '$APPROVAL COMMENTS: <br /> ❑DISAPPROVAL �Ss!rCas a -'--- 17,725- L 1/ <br /> Authorize•Signe ure Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77.202(1)(c)and(d),and 60-2185.and 60.3.169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253.2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />