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mEtti, • - 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 on reverse side. <br /> plicant's Name Type of Ownership <br /> MIDPLAINS CENTER FOR BEHAVIORAL HEALTH CARE SERVICES INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 615 N ELM ST PO BOX 1763 HALL ❑Other(specify): <br /> City State Zip Code Stale 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 /> Pj-e M4 oi- (CO (drr;C ( )LJ4rtdc y /loci S1,e 4-Ax,'I-er Roc. Lean, AI4. &t3'fl <br /> -See crf4tr Ikea /544 o 1 Sot. <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> —_-_•Axaat an additWriatteet,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 /> n are RApsi rrt,ct iscXow,l a001 LIDRfx+entkd 4a& 1E7fiF13Zx1n19a5/1 <br /> Q,rrr�ar-t f' , ;,?wheel c9007 (4t.IF11 tn.1er q_51411-a. <br /> Fan! 1999 Uan if13453ILXfl86/074 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 111 AgriculturavHorticultural ❑Educational ❑Religious NI Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: E YES ❑NO <br /> • <br /> CO ;5 toed -FU iT'enJ�ort- Ctr✓1+`� is atia -rruwx Soni2t $- <br /> e t4 e'd �^ No,give percentage of exempt use: <br /> rJ s ?°r mAih1Enry•7L'P zjnd -� �,rk Ln -���+(,rS }+•r tl,'�q atte:t6 <br /> u+i Ii trailer ctn. AM 4 Me. n4-sW 4 CC epmficyer5 cat atc,.nd5 (4 fe <br /> Qhd btildckic6 f.ep4{GS and Yit4;tt4tnc,rfct . <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 0 � ,t(Z, vP al.-)3 <br /> here Auto -ad Sig•ature dr Title Date <br /> RECEIVES"'°'vY TREASURER e.�E2,47-2 At., 42� X77 �G� <br /> ❑APPROVAL DEC COMMENTS: /. 'Y"- �_ <br /> ❑ DISAPPROVAL E 5 2013 <br /> ?yy'y +,9:a...rz /-.7—'y <br /> HALL COMM 'Signature of County Treasurer Date <br /> 1 GRAND IbUWD.NE WIT' BOARD OF EQUALIZATION USE ONLY <br /> J/ APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 6 rger6 4LL- ems) _ _ /r �i9) <br /> Authorized Signature --- Date <br /> Nebraska Department of Revenue Authorized by Nab.Rev.Stal.§§77-202(1)(c)and(d),and 60-3,165,and 603,169 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />