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ern.---z— Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •TC be tiled with your county treasurer. IMSDIBIECESIMISI •Read Instructions on reverse aide. Applicant's Name Type of Ownership Destiny Church Assembly of God ®Nonprofit Street or Other Mating Address County Corporation 61d$0 {.0001 05(CX 644 SOUTH LOCUST ST Hall ❑Other(apeeiy): City State Zip Code State Where Incorporated Grand Island NE 68803-9500 Nebraska IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code President Tim Rust 6687 N Engleman Rd,Grand Island NE 68803-9500 Board Member Steve Warriner 3411 W Faidley Ave Grand Island NE 68803 Board Member Dwight Sandoz 1891 Hardy Rd St Paul NE 68873-3600 Board:Member--i• Mark Stecker 2204 Woodridge Ln brand island NE ba801 DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,It necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, _ If Newly Purchased Sharp 2010 Cargo 1S9BE1217A1870613 Jan 12,2012 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑AgriculturatMorticuitural ❑Educational N Religious ❑Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist: N YES ❑NO Used to haul props, a sound system, and other electronic equipment from location to location i If n Nebraska for conducting religious services. No,give percentage or exempt use: v Under penalties of law,I declare that I have examined this application and that a is,to the best of my knowledge and belief,true,complete,and correct.I also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. Sign , /2 //�a, _ 7' President Jan 12,2012 here Authorized Signature N v4�v Title Date Ff,tt COUNTY TREASURER RECOMMENDATION PPROJAL RECEIVED COMMENTS: Atn--• Al-°S' S 77- ❑DISAPRROVAL JAM 22 se ® at _.-_.aa./t /-22- 'a HALL CCupey Signature of County Treasurer Date GRAND QTR OR COUNTY BOARD OF EQUALIZATION USE ONLY PPROVAL COMMENTS: 419❑DISAPPROVAL -ce - �. . � in i _` zJ umorized gnature ' Date Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)end(d).and 80-3,185,and 603189 96-253.2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.