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� � , eel <br /> ein.-' 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 /> inismaiarazu •Read Instructions on reverse side. <br /> 4111Applicant's Name Type of Ownership <br /> SENIOR CITIZENS IND ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E 3RD 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,Ci State,Zip Code <br /> 1 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 /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious "Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an�explanaatiio�n it�mulultiiplle�u�seciclassifica tionssexis�t:,lpp,InGk/ ❑YES ❑NO <br /> ��y,�rypt.(.J�lpr. -e9 CJC�KL(J��L.(0 V A " ' '`'' - It No,give percentage of exempt use: <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 duty 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 - j-2 a. <br /> i here Authorized Signature • Ti e Date <br /> C°°-^OI1MTV TREASURER RECOMMENDATION <br /> APPROVAL <br /> RECEIVED �e -' A45 z7- ,-,,,,, a, <br /> ❑DISAPPROVAL DEC 1 6 2 0 1 3- <br /> /-'X(_- .40-4, v -via- <br /> HALL COUNTY /Signature of County Treasurer Date <br /> GRAND TY E OARD OF EQUALIZATION USE ONLY <br /> 0APPROVAL COMMENTS: <br /> ❑DISAPPROVAL — <br /> / 3 At`mss /- /4440l? <br /> /Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 603,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />