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�c�/ � <br /> �•�� Application for Exemption FORM <br /> Nebraska Department of <br /> REr�NVE from Motor VehicleTaxes by Dualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> .... _ . •Read instructions on reverse side. <br /> ApplicanYs Name Type of Ownership <br /> GRAND ISLAND AR�A HABITAT FOR HUMANITY �tvonprotit <br /> Street or Other Mailing Address County Corpvration <br /> 410 W 2ND 5T#6 PO BOX 1001 HA�-�- �Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFIC�RS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,Cily.8tate,Zip Code <br /> � I�� . 2?.3 �.1ord'�� R Gru-..tid ts[�nd .N� �•8�G3 <br /> . P�resi en � ' WO'i-� � ..u7� .i, 7�� f.1- ilba-►� Qd W ocd R.i ve_r . I�� b��l <br /> , �`x2 (3ird�e v i� F $Z�-! <br /> �re a 5�� r-� i Fius .i � i Pc�n .r- a . . . f�-r--��d zs ia ne h5� f�5s£s L�- <br /> DESCRIPTION OFTHE MOTOR VEHICL�S <br /> •Attach an additional sheet,if necessary. <br /> - � Registration Date or <br /> MotorVehlcle Make MvdelYear BodyType Vehicle ID Number �ate of pCquisition, <br /> if Newly Purchased <br /> �.lS�e+GtC.h r �.`�� `'C$ �-F�• I �t$ Ti' .l T�.�tc,r �`�`1 C'$�K ZZw'7Ot�S�3S <br /> � �° r C�c Z S� nr.SX cae �{ '7' � ' Y ?i'7 0 <br /> ��.0 �.r �� F[c��- � J F i��. S �:7 � <br /> Exempt Uses oF Motor Vehide: Are the motor vehicles used exclusively <br /> �AgriculturaUMorticultural �Educational �Religious �Charitahle ❑Cemetery <br /> as indicated7 <br /> Giv�detailed descriptivn of use,including an t3xplanativn if multiple use classifications exist: �y�,e � "�-►"Q�9$�p.�''fa— �YES �NO <br /> �}yc►•. �fi C-c'►�struci-�c�r, rnc:�t�c..r�ais c�r,d t-��i s. t.�srd �ro s:-�-p��r-+ <br /> If No iv <br /> COYiS'1"Y1.cC�"l�� CY'2—cc�S �-jw-.lG�i nL� ��-L�bi+a�� �@]W -InCOm� �(TU-�"1, ' ���i�r� �D <br /> NOV 1 5 2011 <br /> Under penalties of law,I declare that I have examined this application and that it is,to Ihe besl of my knowledge and beli ,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that ihe organization owning the above-liste roperty does noikli�kAr�G'r�N� <br /> in membership or employment based on race,color,or national origin. 'rREASIJRER5 OFF�CE <br /> GRAND ISLANd,N�BF2ASKA <br /> Slgn * ��.GCI..�`1 V`� _ 1 reC�'f I I 1� I� <br /> here Aut orized Signature Title Dat <br /> FOR CAUNT'YTREASURER RECQMM�NDATION <br /> [�PROVAL CbMMENTS: �`S"S � ��� �� <br /> ❑DISAPPROVAL <br /> u � �ydY�� �� c��7 � <br /> Signature of County Treasurer Date <br /> �� FOR COUNTY BOARD OF�QUALIZATION U5E QNLY <br /> �PI'ROVAL COMMEN7S: <br /> ❑bISAPPROVAL <br /> � �=��/�— <br /> uthorized Signature Date <br /> Nebraska Department of Revenue Authori2ed by Neb.Aev.SieL§§77-202(1)(C)end(d),and 60•3,185,and 60-3,789 <br /> 96-253•2006 Rev.B•2o11 Supersedes 96-253-2W6 Rev.5•2009 <br /> PLEASE RETAIN A COPY FORYOUR RECORDS. <br />