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evnLZ Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> EccrEarnrana •Read Instructions on reverse side. <br /> Applicant's N e I 1 Type of Ownership <br /> } J ( L-` ���i( }r(//A onprotit <br /> Street or Other, tiling Addressyy//] \/y1. County Corporation <br /> t� C� / •/a.(/Y©It- .9- <br /> 1- II-s4 ❑Other(specify): <br /> City /p G S`at _ Zip Code State Incorporated <br /> rDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,Slate,Zip Code <br /> , 1 i/ ' , .r, <br /> ft Jr .a _ - <br /> k w . ITRAIuniat rte- ar_ _a/ +!'• x <br /> ifi10 AdE1!<rillllllilfill%3rr' ' ' SAMMT <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 Ne ly P chased <br /> C-keVy &xg,Vc5i G?,�an ao65 16 l G rifr7f-I s/8 nlois- <br /> 1 - 7 G3 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturalMorticultural ❑Educational Religious hantable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: UJ"`S '. ❑NO <br /> 1 <br /> 4 Ck 1,f Tick w.{�(�c (a aaf c i DYxq.LJ( 'Liu ) ^- 4 {trA(L.., t No,give percentage of exempt use: <br /> ilk �,dl+r'1 l I �f-"1 (11'"�/Y-t�l edi ". '. 1'- OecQSnn OWV•- NFL 3i p <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 ih. . duly authorized o sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in members '•or- ployment based 'n race,color,or national origin. <br /> sign - , - Pea; �s -S <br /> —. i�L. f.:l ' <br /> here Au or e. -ign-cure Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> Eill.PPROVA_ RECEIVED COM ENTS E '"" —i,"r <br /> ,az .- '.C.$ #-77.4'ca <br /> ❑DISAPPROVAL _ <br /> JUN 4 2018 osiChadzet- 41.-:-1--/i" <br /> i'Signature of County Treasurer Date <br /> HALL COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> I KENDURt_n$Or-FIDE <br /> GRAND ISLANDL NEBRASKA <br /> APPROVAL COMMENTS: <br /> N. <br /> ❑DISAPPROVAL ' <br /> I � °��/(��/��[gy� p! <br /> Auth'rized Signature Date — Ir (/ <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev 8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />