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� <br /> �� Application for Exemption �oRM <br /> Nebraska Department oF <br /> RE�/ENI 1C from Motor Vehicle Taxes by Glualifying Nonprofit Organizations 457 <br /> .► vC •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> ApplicanYs Name 7ype of Ownership <br /> HALL COUNI"Y C/O SENIOR CITIZENS INDUSTI�IES INC �Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E 3RD ST HAI.L <br /> ❑Other(specify): <br /> City State Zip Code State Where Inwrporated <br /> GRANb ISI�AND NE 68801 NE <br /> IbEN71FY OFFIC�RS,pIRECTORS,OR PARTN�R5 OFTHE NpNPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> DESCRIPTION pF TH�MOTOR VEHICL�S <br /> -Attach en additional sheet,if necessary. <br /> Registration Date or <br /> MatorVehicle Make ModelYear eodyType Vehicle ID Number Date df Acquisition, <br /> if Newly Purchased <br /> Exempt Uses oF Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgricWWral/Horticultural ❑Educational ❑Religious Charitable ❑Cemetery as indicated7 <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ES �NO <br /> �rovi�es u.bl�c.`�"raxti��or�',�.o�'�t�. <br /> e: <br /> e�earl� '� cx�r►.d er��_ <br /> � � � <br /> �l i c. t�t`4-h�n - <br /> D EC 1 5 2011 <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my knowledge an belief,true,com I a I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above listed propert�����MGCS <br /> in membership or employment based on race,color,or national origin. ��ryp ISI.AND,NEBRA5!<A <br /> Slgl'1 � - 1 <br /> h�re Auchorized Signature p�t9 <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> �PPROVAL COMMENTS: SS �/ -oZCJ .� <br /> ❑DISAPPROUAL <br /> � �c�' a'/` �� <br /> Signature of County Treasurer Date <br /> FOR COUNTY BpARD OF E�UALIZATION USE ONLY <br /> �PPR�VAL COMMEN7S: <br /> ❑DISAPPROVAL <br /> � ���� <br /> uthorized ignature qa�� <br /> Nebraska Pepartman�of Re�enue Authonzed by Neb.Rev.Stat.§§77-2o2(t)(c)and(d),and 60-3,185,and 60-3,189 <br /> �96-253-2006 Rev.8•2071 Supersedes 96-253-2006 Fiev.5-2009 <br /> PLEASE R�TAIN A COPY FOR YOUR RECORDS. <br />