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v/3 <br /> Nae.aske DeppaaRtmeent of Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br />• •TO be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> • GOODWILL INDUSTRIES OF GREATER NEBRASKA INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1804 S EDDY ST PO BOX 1863 HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> P�1< ATTf#MI b <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> _ Registration Date or <br /> - - - ----Motor Vehicle Make-- Model Year -- Body Type -" Vehicle ID-Number - Date of Acquisition, <br /> if Newly Purchased <br /> trk <br /> A-rriketkn, <br /> Exempt Uses of Motor Vehicle: r/ Are the motor vehicles used exclusively <br /> Agricultural/Horticultural Ild Educational Religious as indicated? <br /> ❑ g T ❑ g" ❑Charitable ❑Cemetery <br /> Give detailed description of use,including an explanation if multiple use classifications exist: IYI YES ❑NO <br /> L` r- p ID-k t c wt' c+-n a }Rktr.c karne clteAks ct' Swart If No,give percentage of exempt use: <br /> CV.4145 cs_CV\V knee and Ics-c A(N..nc1. A\moo t...s¢d erg <br /> CIAO j y�S {fit 51.A.11 eud �i p�ibLHLS 'o <br /> oQ dyycsb : tcs . <br /> COnkcLeA 6scb S Ptak_ 2,f5 4A gc,co <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.I <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 amp'. ment based on race,color,or national origin. <br /> sign fj, / <br /> I(-io i7 <br /> here 'I th.rized Spa/ Ttle Dale <br /> •• COUNTY TREASURER RECOMMENDATION <br /> APPRd/AL RECEIVED Co •MENTS.46neT" /C-n"1 "Y'5 J '7` ✓ g a <br /> ❑DISAPPROVAL kiri, r• nn,+•) <br /> i 0 L.1L <br /> HALL COUNTY Signature of" County Treasurer Date <br /> - . .• ;RASIVFOR ••UNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> / /rte _sue ® 1— �S0n/3 <br /> • Authorized Signa ure Sor Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev Stet.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />