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ao/3 <br /> 'kii--L_ 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 /> intnui •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> HALL COUNTY C/O SENIOR CITIZENS INDUSTRIES INC ®Nonprofit <br /> Streaker Other Mailing Address County Corporation <br /> 30&E 3RD ST HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title (� Name,Address,City,State,Zip Code <br /> -7°-� � ��ert L Q .�', ± <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> i *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 /> it Newly Purchased <br /> I <br /> ti sM t w►7a%taifl i <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br />• <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: ES ❑NO <br /> • .)• 1eS ?Wok; �i v ,r_ b4 <br /> �' ` f If No,give percentage of exempt use: <br /> e `cler l t� ho sid;eq��ed o�ge z�eerci A7 vim{ l� <br /> l.k ► ib,r <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 /> P PP Y 9 P <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 / a <br /> here Authorized igneture ' die Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> PROVAL COMMENTS: • $ /Cee~--d ry'is 77°`7°a <br /> ❑DISAPPROVAL <br /> tiSignature of County Treasurer Date <br /> v. ��®w e^t FO . OUNTY BOARD OF EQUALIZATION USE ONLY 1 <br /> SLAPP••••L OQ�I. CO i ENTS: <br /> ❑DISAPP 'OVAL O1LC GO sp 6 �5_ <br /> e y��NO Ne ��,., tee_•._i_Zer Dale �CVL# <br /> 4111 �r<toz Authorize.Signature Date <br /> nf�NO <br /> Nebraska Department of R..,nue Authorized by Neb.Rev.Stat.§§77-202(11(c)and(d),and 60-3,165,and 60-3,169 <br /> 96-253-2006 Rev.6-2011 Su, r- --96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />