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r o <br /> Inen_--t___ 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 /> •Read instructions at reverse side. <br /> Applicant's Name Type of Ownership <br /> HALL COUNTY 010 SENIOR CITIZEN INDUSTRIES,INC. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E. THIRD 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 ' k Name,Address,City,State,Zip Code <br /> "SEE ATTACHED LIST" <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> I 1 Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle lD Number Date of Acquisition, <br /> if Newly Purchased <br /> BRAUN HANDICAP _ 2014 VAN 2C7WDGBG6ER220356 4/23/14 <br /> BRAUN HANDICAP 2014 VAN 2C7WDGBG4ER220355 4/23/14 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educationat ❑Religious ®Charitable ❑Cemetery as indicated? <br /> • <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES 0 N <br /> •Provide public transportation of the elderly, handicapped,and general public within Hall No give percentage of exempt use: <br /> County. <br /> i <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 �. . ., - ass .11 - if, 1 . , • 5 _cvv.i y <br /> here 'Authorized Signature Title , - Date <br /> Ill <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> EAPPROVCL <br /> RECEIVED trim RENTS: I _ - ,2/AJ A l it.' 77 ate ' <br /> ❑DISAPPROVAL <br /> 2014 jj��//��(( °`�' .5� �.9°ice <br /> MAY 2 3 I Signature of County Treasurer Date <br /> FOR CCUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE <br /> APPR0Vd GRAND ISLAND,NEBRASKAf:WENTS: <br /> ❑DISAPPROVAL <br /> • i in caz-5//� <br /> Authorized Signature a <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)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 />