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Application for Exemption
FORM
from Motor Vehicle Taxes by Qualifying Nonprofit Organizations
457
• To be filed with your county treasurer.
• Read instructions on reverse side.
Applicant’s Name
Type of Ownership
Nonprofit
Street or Other Mailing Address
County
Corporation
Other (specify):
City
State
Zip Code
State Where Incorporated
IDENTIFY OFFICERS, DIRECTORS, OR PARTNERS OF THE NONPROFIT ORGANIZATION
Title
Name, Address, City, State, Zip Code
DESCRIPTION OF THE MOTOR VEHICLES
• Attach an additional sheet, if necessary.
Registration Date or
Date of Acquisition,
Model Year
Vehicle ID Number
Body Type
Motor Vehicle Make
if Newly Purchased
Exempt Uses of Motor Vehicle:
Are the motor vehicles used exclusively
as indicated?
Agricultural/Horticultural
Educational
Religious
Charitable
Cemetery
YES
NO
Give detailed description of use, including an explanation if multiple use classifications exist:
If No, give percentage of exempt use:
%
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
also declare that I am duly authorized to sign this exemption application, and that the organization owning the above-listed property does not discriminate
in membership or employment based on race, color, or national origin.
sign
here
Authorized Signature
Title
Date
FOR COUNTY TREASURER RECOMMENDATION
APPROVAL
COMMENTS:
DISAPPROVAL
Signature of County Treasurer
Date
FOR COUNTY BOARD OF EQUALIZATION USE ONLY
APPROVAL
COMMENTS:
DISAPPROVAL
Authorized Signature
Date
Nebraska Department of Revenue
Authorized by Neb. Rev. Stat. §§ 77-202(1)(c) and (d), and 60-3,185, and 60-3,189
96-253-2006 Rev. 8-2011 Supersedes 96-253-2006 Rev. 5-2009
PLEASE RETAIN A COPY FOR YOUR RECORDS.