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men— Application for Exemption FORM Nebraska Department of REVENUE 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 Destiny Church Assembly of God ®Nonprofit Street or Other Mailing Address County Corporation 6NDON)040304CKRock 644 SOUTH LOCUST ST Hall 111 Other(specify): City State Zip Code State Where Incorporated Grand Island NE 68803-9500 Nebraska IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Coda President Tim Rust 6687 N Engleman Rd,Grand Island NE 68803-9500 Board Member Steve Warriner 3411 W Faidley Ave Grand Island NE 68803 Board Member Dwight Sandoz 1891 Hardy Rd St Paul NE 68873-3600 Boa rd.Member.r Mark Stecker 2204 Woodridge Ln Urand Island NE bum DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,it necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, if Newly Purchased Sharp 2010 Cargo 1S9BE1217A1870613 Jan 12,2012 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively 111 Agricultural/Horticultural 111 Educational ®Religious ❑Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation it multiple use classifications exist: ®YES ❑NO Used to haul props, a sound system, and other electronic equipment from location to location It No,give percentage of exempt use: 0 in Nebraska for conducting religious services. q 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 , m f '-- President Jan 12, 2012 here I Authorized Signature Title Dale FOR COUNTY TREASURER RECOMMENDATION �7 [kAPPRO/AL RECEIVED COMMENTS: 4 " '!7 �`' �S: S. 6 7' `7C'CZ' ❑DISAPPROVAL Am 22 Ir C L ,, ae c._[.sr./z, /-ate?-/3 NALL COUNTY Signature of County Treasurer Date Nog ��J// 6�p��OF OR OOUNTY BOARD OF EQUALIZATION USE ONLY $APPROVAL COMMENTS: //❑DISAPPROVAL ' AO °254-- ell „sue. ill "thorized ignature 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 96253-2006 Rev.6-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.