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t��.—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 /> inminerri •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> GOODWILL INDUSTRIES OF GREATER NEBRASKA INC <br /> I X Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1804 S EDDY ST PO BOX 1863 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 /> f/f fir"Afilit0/ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> -- - - - -Registration Dale or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> PAe HTrfi'.J j <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural cil Educational 1111 Religious ❑Charitable ❑Cemetery as indicated? <br /> aced? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: DCI YES ❑NO <br /> L.Scd -Vac p«k.tr. ank- . .rs h� at t(* or 5"itrit If No,give percentage of exempt use: <br /> •°-C ci tr)cs ac�rtrt-tits and *crcn s. • P.•\$O L d uJ i <br /> -• 'ro4.-\:tiq o ? dona4rtoft 46.k Ppett't..ou-r <br /> pro 3ra.a O d sexAc.,,l c rtes . <br /> Q-z' l*a-c* Barb Sc,e &&k-14159co Kt4 <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 above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign i.(/`' c FD fi-.av-/3 <br /> here ■Authorized SI ture Title Date <br /> I RECEIVED run BOUNTY TREASURER RECOMMENDATION <br /> PROV kL COMMENTS: �L'.7Ya t A.6- 1-: A' S• 77'"� , <br />• <br />• <br /> ❑DISAPPF OVAL NOV 2 2 2013 <br /> `-"` j' X ..a., 2. /- --./y• <br /> HALL ERS O Y /Signature of County Treasurer Dale <br /> TREASURERS OF 't.� <br /> ��,,// GHAND ISLAND,NEB a rr UNTY BOARD OF EQUALIZATION USE ONLY <br /> 111GAPPROVAL COMMENTS: <br /> YY❑''""DISAPPROVAL <br /> ALt� /-Z d <br /> Au1hI prized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,165,and 60-3,169 <br /> 96-253-2006 Rev 8-2011 Supersedes 96-253-2006 Rev.6-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />