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. — 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 /> Good Samaritan Society Grand Island Village ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4075 Timberline Street Hall ❑Other(specify): <br /> City State rip Code State Where Incorporated <br /> Grand Island NE 68803 South Dakota <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code i <br /> cee AIJACNed <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 /> N Newly Purchased <br /> Dodge Ram 2001 _ regular cab shortbox 1 B7HF16Z815707690 12/27/12 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural El Educational ®Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> Facility Use If No,give percentage of exempt use: <br /> Hauling and picking up parts,furniture, appliances, etc. <br /> Snow Removal <br /> Hauling and picking up landscaping materials, plants, etc <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 above4isted property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign k Administrator 12/28/12 here I Auth&A: `1 <br /> Signature Title Date <br /> ' FOR COUNTY TREASURER RECOMMENDATION <br /> APPPOVAL RECEIVED COMMENTS: .eleAnat ' "4/SS 77- go ' <br /> 2W3 <br /> ❑DISAPPROVAL JAN _ 2 2,,a <br /> ,7 /.3 <br /> HAIL COUNTY Sign000u Treasurer Date _ <br /> — TPrAcur r-- 6r✓?Ca <br /> GRAND ISLAND,NEBRASKA FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> 9.APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> �/- /-a c'' i/' ., /_I/ //St ' is <br /> orized ignature Or Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3.185.and 60-3.189 <br /> 96-253-2106 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />