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m^—_— 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 /> •Reed Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> ( 1 <br /> k1Ut( ttrnn(i 4R ..{VI (Etl-k'.f ;Dv _ A Nonprofit <br /> Street or Other Mailing Address ,�/� County ..Corporation <br /> l \'3 C(4)ik1 stArskd\ue HO- t ❑Other(specif): <br /> City n State Zip Code State Where Incorporated <br /> braRO 13«n(1 N€- to 3-I-7-i�--1 _ kae�ro`prCst <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> T i c e•;e,. tAnric(5rn-Pty. lt—-t 'co-ih lochs--i S+ Napa LsviM NF ioTh t <br /> ' 2 • - i t I •' . al ILA s • _!,_ +;.a .- <br /> M NW MED LIIM rffilEg.M=n Or I lei• irti.. <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 /> it Newly Purchased <br /> Thl 2011-1 Cttinvnn )Q.4.tttLP4-2EL2 S12 Clap CA- <br /> Exempt Uses of Motor Vehicle: i j Are the motor vehicles used exclusively <br /> ❑AgdculturabHorticultural ❑Educational ❑Religious rUyy C■hedleble ❑Cemetery indicated? <br /> Give detailed description of use.Including an explanation It multiple use classifications exist v�n�� DYES NO ' <br /> TfairG ^-'. w 11Xn-Co(' txtt€vt5 1 U I- YtX✓n "Qi�31(11' , '� 1+ If No give percentage of exempt use: <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 properly does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign � e t ' Fxtrxn 1113 �ir��� 1't12cti l 1 <br /> here , s a Title Date <br /> pp r 1TY TR:.SURER RECOMMENDATION ewe jaw Is <br /> PPROVAL COMMENTS: /. i ,- - L -AI aa — — - <br /> ❑DISAPPROVAL <br /> HALL <br /> SURERSNTY 0 Q�r3l/�• <br /> TREASURERS OFFICE �Sg ture of County 'z�Se <br /> nRANn tst AN NESRASK <br /> OR COUNTY BOARD OF EJUALIZATION USE ONLY I <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL t---, <br /> , . <br /> /r ilk-- cam-.. --4:Aul '•naW� Date <br /> Nebraska Department of Revenue Authhorized by Neb.Rev.Stat.§§77.202(1)(c)and(d).and 60-3,105,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.6-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />