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y <br /> Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To he filed with your county treasurer. <br /> aaoaeaTV asse_sraemr •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> ilk HALL COUNTY CIO SENIOR CITIZEN INDUSTRIES INC. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E. THIRD 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 /> **SEE ATTACHED LIST** <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear BodyType Vehicle ID Number g Date ot,Purchased <br /> FORD 2013 BUS IFDFE4FS9DDA44732 04/04/13 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> as indicated? <br /> ❑Agricuhura&Honicuhural ❑Educational ❑Religious ®Charitable ❑Cemetery <br /> Give detailed description of use,Including an explanation if multiple use classifications exist OYES D NO <br /> Provide public transportation of the elderly, handicapped, and general public within Hall <br /> if No,give percentage of exempt use: <br /> 4111County % <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 /> this exemption application,and that the organization owning the above-listed properly does not discriminate <br /> also mbers ip o I em loty ent based on sign or na app <br /> in membership or employment based on race,color,or national origin. <br /> sign 4m • • a _� - /4/1 at. Executive Director Aq -1 3 <br /> here than -•Signature , Title Date <br /> RECENEDFOR C' UNTY TREASURER 1 A/-4-� , 7J-�C <br /> [APPROVAL 11 COMM NTS: " <br /> 0 DISAPPROIAL RI M l 2013 <br /> LO„ .c( ,ate ' -.9":"/—./IS <br /> HALL CmRm It S' nature of County Treasurer Date <br /> OHANIJ IAADSNE OFFICE g <br /> • . BOARD OF EQUALIZATION USE ONLY <br /> It APPROVAL COMMENTS: <br /> 0 DISAPPROVAL r / ' S <br /> Monied Signature r Date <br /> Nebraska Department of Revenue Authorized by Nen.Rev.Slat§§77-202(1)(c)and(d),and 60-3,186,and 60-3,189 <br /> 96-253.2008 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> I. <br />