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o2a /3 <br /> lor^-- __ Application for Exemption FORM <br /> Nebraska Department of <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 /> 0 GRAND ISLAND AREA HABITAT FOR HUMANITY ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 410 W 2ND ST#6 PO BOX 1001 HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Jusfn ( t bIl I 1?22 w, KOerii9 , GI ,N1= G,Byo3 <br /> Tra.Vis Q&SFl Kw) nn all Poridcresa der GS NE 6K8b3 <br /> IJ a I i e. E•.d rcut 2140 Par K Ave , tyz. NE ro 88.03 <br /> 77R4hlti UJe i+asztwsk- I 731 N, Ilom ket w2 ME 6Kfre3 <br /> -J DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> -- - --Molor-Vehlole Make - - --Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> _ if Newly Purchased <br /> Glut C bog Pk tic cy 14Trc1LIC9g7-9O 1 °74 , <br /> US Oros &'c.-KS `jgt 'Wc'41• 16158 tonI - rDiter iLi- CSI BZ2W7005 $'35 <br /> Cdr1hnen -Lc.' rr,r-yr, ZS•fottt'S ZOO o, 'i-n01 +ruil'er 4A 41-7"- a% ZSYNOI7OBf <br /> H c 4 7 r ik i ter ZC05 ciea pert 4Ji,LIE- I gas. cAc-71g(rl <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational El Religious 1 `e aritable ❑Cemetery as indicated? <br /> Give detailed description pf use,including an explanation it multiple use classifications exist: S ❑NO <br /> roc:A re_ <br /> o-To Li t cK" u-f1A kC)VIAL I, -p co ire rrwr t pad U C'f O iA a.'h a r15 -it-1/— <br /> 1_ 1 y' If No,give percentage of exempt use: <br /> • Vev e•f1+ a- Ho;v",'-i-, 4FS kew' 1•\ row, c k0 " sli., n oc cLn-1 , % <br /> o <br /> ,, Fo r 61'or -rie 4, -1'rekwspc ,-+ ewF CenS4F-ruc+ion ma-Verluis a�cL <br /> +vo15 . - <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 employment based on race,color,or national origin. <br /> cti;. /x_ez_t___ <br /> sign l /f4 C . I0, 1Ziiil z <br /> here I Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> IPPROVAL RECEIVED COMK€NTS•214-4"'" /Ia.." 4.9:515- 77-eP° <br /> ❑DISAPPRCYAL <br /> DEC 1 1 2012 <br /> .0-49P744 X6 0—aa.4-. !a-// <br /> r Signature of County Treasurer Date <br /> Ralf C/7UN r OR COL.NTY BOARD OF EQUALIZATION USE ONLY <br /> TRFI.4A LCOU EDRASF <br /> _ QRAI'!D ISLAND.D.NEBRASKA <br /> Vc'APPROVAL COMMENTS: <br /> ❑DISAPPROVAL j <br /> r - fie A, 07001J .n./5 <br /> • thorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.88 77-202(11(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 />