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� �-�a r�— <br /> ��- Application for Exemption �oRM <br /> Ne6reska bepartment of <br /> REVENUE from Mator Vehicle Taxes by Qualifying Nonprofit Organizations �c� <br /> •To be filed with your caunty ireasurer. J <br /> •Read instructions an reverse side. <br /> ApplicanYs Name Type of pwnership <br /> MIDPLAINS C�NTER FOR BEHAVIORAL HEALTH CARE SERVICES INC �Nonprofit <br /> Street or Other Mailing Address County Cvrporation <br /> 615 N ELM ST PO BOX 1763 MA�L ❑other(specity): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 688Q2 NE <br /> Ib�NTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> � p �drr1-r� o scc5lt �� � �Iosg .rnc►i�.�h�� Dri�� GnyKd z5 , 6U�. 6 S$c 3 <br /> ice r` 'dty C � _ - oel Y..r � G3 GJ- 0�' S'fi'e� r�ne z"s�aKd N�c. �`c�c� <br /> - � � `d rn�- r� r<5k � ax 7� G k oU ���Z <br /> Se� , #hcl�r�f 1°�-� ��' $c�:� <br /> DESGRIPTION pF THE MOTOR VEMICL�S <br /> •Attach an additional sheet,if necessary. <br /> Repistratinn Date ar <br /> Motor Vehlcle Make Mndel Year Body Type Vehicle Ip Number Date ot Acquisiiion, <br /> If Newly Purchased <br /> ORD 1R�i ��-hd17 I DX�ya�"1 �g 4�5� <br /> acr ' caUU il: 7rn; -er 08 77r►'!� < 7 <br /> L� T iS'oc� � o F a5' <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educationel ❑Religious [�Charitable �Cemetery as indicated7 <br /> Give detailed description of use,including an explanation if multiple use classifications exist: �YES �NO <br /> Uk�l,'-*�- ��1�� ��� ks� c�' rnk�v���,�c.e ew,P��y�S s�;o,.nds carea�c b��it�lx� r�P��r� ���i����� <br /> l-t�d h'�k.+'I-�drl�viC�. ,�PG► ldS[d -�c� ii`wn t'f G .�f If No,give <br /> S,P� j ✓� �n Frrld fr'j�s; �c aKd�,.�.-. �Srrvice5� <br /> �in� �k �l-J-e�Y�ry�- pl�crs v�= n'ire. J7�d�� �tS�c! �f Wl,s''I.�Cc1k'7L2 4,Y�[.F ����.� c.p i <br /> S'���lic5 ���-r O�s r7�Ic�.x;$ , NdV 2 3 2011 <br /> HALI.CqIIN"fY <br /> Under penalties oi law,I declare that I have examined this application and thai it is,to the best of my knowledge and beli ,true,co ,"i� ' �g�qSK,q <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed r F <br /> in membership or employment based on race,color,or nativnal origin. <br /> sign Y ��/�Fa �a"31-ao I1 <br /> here Autho ed Sign ture w 7itla � Date <br /> FOR CDUNTY7REA5URER RECOMMENDATION <br /> �PPROVAL COMMENTS: � �%�v�*� <br /> �DISAPPRQVAL <br /> / ! i��'T r� <br /> �Signature of County Treasurer pat <br /> FOR COUNTY B�ARD OF�pUALITATION U5E ONLY <br /> �PRpVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> ��....,Lsz�_. <br /> Authorized Signeture Date <br /> Nebraske bepartment of Revenue Authorizad by Neb.Rev.Stat.§§77-202(1)(c)end(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supsrsedes 96-253-2006 Flev.5-2D09 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />