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Nom_ Application for Exemption FORM <br /> Good Life.Great service. from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •To be filed with your county treasurer. 457 <br /> PE•••,--or n"-E •Read instructions on reverse side. <br /> Name of Organization Type of Ownership <br /> TEHAMA SHRINE/CENTRAL NE SHRINE CLUB ®Nonprofit Corporation ❑Other(specify): <br /> Name of Owner of Property County Name State Where Incorporated <br /> HALL NE <br /> Street or Other Mailing Address Contact Name ,/ Phone Number <br /> 417W3RDST POBOX49 Wa RaE Ytcv` ,y'o8- 379-. 173 <br /> City State Zip Code Emal Address <br /> GRAND ISLAND NE v,} e V t Cs-n ? e 3 rvna_`. . Co %✓l <br /> Identify Officers,Directors,or Partners of the Nonprofit Organization <br /> Title Name,Address.City.State,Zip Code <br /> Pre: -. - $e , , - L . . 2 . ..' /f• .l .. . e rnf <br /> _r _ • �i•Qh •- - c .A 5 '�G•SiE�CAC, MIragl. 03 <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 /> De r1 e, gio.m 15os d.(�o a Prvkte I n 71i A he A.2srs7I S 94 <br /> Corr $ cttP. sn•tiere, f•I'na bt ;tr�oe ,Itra: --3 OS <br /> 1t It It I .,a1D t-aik,r 5A a ri <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural and Horticultural Society ❑Educational ❑Religious Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: X YES ❑NO <br /> T�te,ptrxf, a is us.ted to pull .. oC 'Hy_ 4ra,il�rs w xtA4, ie6` <br /> �, j ,,' I i ( II No,give percentage of exempt use: <br /> S k&url qo-cab\ it Droi.G1R.l. . fin vei'`tcdeo Lt4 4rai(.o.vis <br /> Cw-e ;ur 14.e, tie 01- 0 CAA 4i-ctA /'JeE ka Sket`vte 0 tu-b <br /> 0 1\kAat 1. <br /> Und nalties of law.I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and complete. <br /> I also d re that I am duly authorized to sign this exemption application. <br /> Sign 4, 7.�iel„J Seri, t.4 t$Z iO✓' ii.- -2012 <br /> here •Authorized titre Title Date <br /> IFor County Treasurer Recommendation. <br /> t�ypproval 'tty E1VEDomment: quit Ft!` 6_, miss 1-1•f0� <br /> �[❑Disapproval DEC 4 2018 ` <br /> I ! I IS I_.1. 11 I 12\11\1% <br /> Signature of County Trees -r Date <br /> HPtt-e9or•re— <br /> TRFASt)RERS OFFICEor Cour ty Board of Equalization Use Only <br /> — GRAND ;—.--.--•-••--•"'"'". <br /> N <br /> V]Approval Comments: <br /> t , <br /> ❑Disapproval - ' <br /> 7 <br /> Aufhor' etl Signature Da / <br /> Nebraska Department of Revenue authorized by Neb.Rev.Stat.§§17-202(lllc)and bb,and 60-3.185,and 60.3169 <br /> 96-253-2006 Rev.7-2018 Supersedes 96-253-2006 Rev.8.2011 <br /> Please retain a copy for your records. <br />