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TO BE FILED WITH Exemption Application FORM YOUR COUNTY for Tax Exemption on Real and Personal Property by Qualifying Organizations 451 ASSESSOR Read Instructions on reverse side. • LFailure to properly complete or timely file this application will result in a denial of the exemption. Naame of Organization County Name Tax Year Head Start Child and Family Development Program, Inc. Hall County 2012 Name of Owner of Property State Where Incorporated Head Start Child and Family Development Program, Inc. NE . Street or Other Mailing Address of Applicant Total Actual Value of Real and Personal Property Parcel ID Number 123 N. Marian Road $50,000.00 City State Zip Code Contact Name Phone Number Hastings NE 68901 Deb Ross 402-462-4187 ext. 148 Type of Ownership ®Educational Organization ❑Religious Organization ❑Chartable Organization ❑Cemetery Organization Name Title Officers, Address,City,State,Zip Code Directors,or Partners Deb Ross Executive Director 123 N. Marian Road, Hastings, NE 68901 Barbara Sunderman Board President 123 N. Marian Road, Hastings, NE 68901 Legal description of real property and general description of all depreciable tangible personal property,except licensed motor vehicles , - Lot One(1)and three(3)of Warren Third Subdivision, Grand Island, Hall County, Nebraska 111;010-10%V) 5lUg5If SEP 052012 f Pa; Property described above is used in the following exempt category(please mark the applicable boxes): ,r ❑AgriculturaVHorticultural Society' ® Educational ❑ Religious ❑Charitable ❑ Cemetery Give a detailed description of the use of the property: Equipment and property for use in our preschool.Additional programmatic use for our children, parenting,community awareness, and administrative functions. All organizations,except bran AgriculturaVHOrticultural Society,must complete the following questions. Is all of the properly used exclusively as described above? - ®YES ❑NO Is the properly used for financial gain or profit to either the owner or organization making exclusive use of the property? OYES ®NO Is a portion of the property used for the sale of alcoholic beverages? ❑YES ®NO If Yes,state the number of hours per week is the property owned or used by an organization which discriminates in membership or employment based on race,color, or national origin? ❑YES CI NO Under PB nalties of law,I lare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and co !so declare am duly authorized to sign this exemption application. sign m � Executive Director 9/4/2012 here Aut (gnat Title Date FOR COUNTY ASSESSOR'S RECOMMENDATION ICI P r APPROVAL COMMENTS: at,- ❑ APPROVAL OF A PORTION , a • , , _IS au_ ❑ DENIAL Signature o•• Assessor e�� . FOR COUNTY BOAR n 1 EQUALIZATION USE ONLY I declare that to the best of my knowledge and belief,the determination made by the County Board of Equalization is correct pursuant to the laws of the State of Nebraska. R APPROVED COMMENTS: ❑ APPROVAL OF A PORTION ❑ DENIED - 1 c _ � �( 'ignature of County: 'e bar ate COUNTY CLERK:A legible copy of this form showing the final decision of the County Board of Equalization must be delivered electronically to the Nebraska Department of Revenue within seven days after the Board's decision. RETAIN A COPY FOR YOUR RECORDS. Nebraska Department of Revenue,Propety Assessment Division Authorized by Neb.Rev.Scat.§§77-202.01 and 77-202.04 90.135-1999 Rea 7-2012 Supersedes 96135.1999 Rev.7-2010