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jai/ <br /> • <br /> - � Application for Exemption' FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> *Applicant's Name Type of Ownership <br /> HALL COUNTY C/O SENIOR CITIZENS INDUSTRIES INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E 3RD ST HALL ❑Other(specify): <br /> City Stale 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,City,State,Zip Code /� <br /> .Saer c�)n v..vcO _ariot <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> _. ... Date_ <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Dale of Acquisition, <br /> if Newly Purchased <br /> k50-Q...- <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 111 AgricultumUHorticultural ❑Educational ❑Religious heritable 111 Cemetery as indicated? <br /> Give detailed description of use,including a/nn explanation tiff multiple use classifications exist: y-7� sae", <br /> //Q��� ,��r ES ❑NO <br /> • 7 Q, h[.C_-C-C.PJ.L�' ez y "'2' sae", 11 No,give percentage of exempt use: <br /> c -y• <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 / <br /> /IA Imo_ . LL.:. ,/t,a i._._ ._ __� /—L'_ / r /a /0 '/.3 <br /> here ' th•'zed Signature i e Date <br /> �•• •1 `TY TREASURER RECOMMENDATION <br /> FRI<PPROVAL COMMEN S: •A - -"S42t ,fiat'••L.• J. cl". I7- ='7Z7-C. <br /> ❑DISAPPROVA DEC. j 0 Cu yid <br /> 2 d ` ? .? --i y <br /> HALL COUNTY • Signatureof ny Treasurer Date <br /> RAND ISLAND N-_; ;..1 . • tO• -D 'FE, : I nTIo. sN Y <br /> AAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> it Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.H77-2020)(0 and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96.253-2006 Rev.5-2009 <br />• PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> 1 <br />