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2013 <br /> Nebraska Department of Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> DONIPHAN UNITED METHODIST CHURCH/DBA LITTLE MIRACLES CHILD CARE CENTER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 303 N 6TH ST PO BOX 188 HALL <br /> El Other(specify): <br /> City State Zip Code State Where Incorporated <br /> DONIPHAN NE 68832 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Acrdnistrative Team Chair Laurie Lueck 4030 W Rosedale Rd Dmiphan NE 68832 <br /> Church Treasurer Mark Haskins 240 W Binfield Rd Daniphan NE 68832 <br /> Little Miracles Director. Amy Wilson 103 N Derby Giltner NE 6841 402-845-2766 <br /> Trustee Chairperson Dee HedTen 349 Sunset Drive Doniphan NE 68832 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> *Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year _ SodY A'pe. _._. _. ___VehicleID-Number__ __. .___Date.of Acquisition, <br /> - - - _ if Newly Purchased <br /> 2001 CH'EVY SPORT VAN 2001 EXPRESS VAN 1GAiG39R911205760 I 1Q5/ 11 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ID Educational in Religious El Charitable El Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: l]YES ❑NO <br /> If <br /> • To LLdnsport children to and Lull activities. No,give percentage of exempt use: <br /> To transport youth group children to and Lim activities. <br /> 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. <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign ,(/p'/�JSjnJ( r2Y � 61 <br /> 1taH a- <br /> here rAuthorized Sin tuna Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> 'APPROVAL COMMENTS: C"—EAtutu' /'r'W alss 77- -Vg=2. <br /> ❑DISAPPROVAL <br /> 1Iy9r 3(c- " i.� i�-iz <br /> P Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> eAPPRO RECEIVED CO MENTS <br /> ❑DISAPP•OVAL <br /> 4, <br /> DEC 1 4 2012 -, , ���.,�,. , gat- <br /> • uthorize.Signatu - Date <br /> Nebraska Depart :.t of Revenue s QF�E� � E Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(b),and 603,185,and 60-3,189 <br /> 96-253-2006 Rev.8- 011 Super 3� ey KSA <br /> •SE RETAIN A COPY FOR YOUR RECORDS. <br />