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<br /> =z-- 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 /> • MIDPLAINS CENTER FOR BEHAVIORAL HEALTH CARE SERVICES INC ®Nonprofit
<br /> Street or Other Mailing Address County Corporation
<br /> 615 N ELM ST PO BOX 1763 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 /> Prebatif+ ' la C£U Cot(IC Edwards, 1I0d5 Sweeiulgfer Ave, KecirAe'. Alt 68SH7
<br /> V:rc-nes;den+ / CFo 3.Q.1 KW& , 403 ti /0" 53reet, (rgndzsllth0, Alt 6no1
<br /> tAte-Pres:dent 141't Lr,;ak, Sex 74, t/Arts, A1£ 6• 4,jN
<br /> 'See 9HaCMd (;y}oF BCD
<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 /> Do Ole Fstioi rrvcK Isar ,i 3001 L>q, FTfr tkd cot, 16714F l3ZX 1519075r 1
<br /> C.Lerva do cc" , o2 wke:el , on C14 1;+7 Tniie-r NYM it LOS I nft10557t
<br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively
<br /> ❑Agncultural/Horlicultural ❑Educational ❑Religious ®Charitable ❑Cemetery
<br /> as indicated?
<br /> Give detailed description of use,including an explanation it multiple use classifications exist: 17tYES ONO
<br /> DoJpe ;5 a5ect ccr sY1q;n-Ftnt,NCe wnb r p;t- Lip Sv lies or a er44-kn 5. 17
<br /> 40 col- If No,give percentage of exempt use:
<br /> iott}il;lt tcq UN Fot M.Sc. ok m4,'•rk ntancc eni,lviees co,cttcvnds tetrc
<br /> clad $vild;nts re.p..r.' •tna ,v,e.4te6trintt_
<br /> Under penalties of law,I declare that I have examined this application and that it is,to the best or 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 /> sign _,� _� VP/GFO 11-5- 6/A
<br /> here Autho Sign- ure Tile Date
<br /> AP r ._,y LMENTS:COUNTY TREASURER RECOMMENDATION I
<br /> PROVAL C •(k • /6244" y5s 77-,a)3-i
<br /> p DISAPPROVAL , _ ,7,,y
<br /> ,,... 7--vat
<br /> HALL Cc)urfl'V ,Signature of Cofl� Date
<br /> 1 rt eS PSHS OFFICE FOIli COUNTY BOARD OF EQUALIZATION USE ONLY
<br /> [.APPROVAL COMMENTS:
<br /> ❑DISAPPROVAL
<br /> . 3
<br /> i ._i -,iIL _!i,- if/ - b/S t,2O J
<br /> uthorized Signature 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 /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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