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• <br /> iiti"---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 /> •Read instructions onreverse side. <br /> Applicant's Name Type of Ownership <br /> HALL COUNTY C/O SENIOR CITIZEN INDUSTRIES,INC. Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E. THIRD ST. HALL <br /> ❑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,City,State,Zip Code <br /> **SEE ATTACHED LIST** <br /> 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 /> BRAUN HANDICAP 2014 VAN 2C7WDGBG6ER220356 4/23/14 <br /> BRAUN HANDICAP 2014 VAN 2C7WDGBG4ER220355 4123/14 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgnculturalHoracultural ill Educational ❑Religious ®Charitable 111 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES LINO <br /> Provide public transportation of the elderly, handicapped,and general public within Hall <br /> County. If 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 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 A .. . 'u • ' - A • S -,Vv-fig•here Authorized Signature Title Date <br /> ,,��,,,,�� FOR COUNTY TREASURER RECOMMENDATION <br /> LWjAPPRO�VL RECEIVED wrKAENTS: f' �� M 77- a�� <br /> ❑DISAPPROVAL <br /> MAY 2 3 2014 ,Signature of Treasurer Date <br /> FOR CC UNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COuN <br /> TREASURERS OS OFFICE <br /> jAPPROtg) GRAND ISLAND,NEBRASKACOMAENTS: <br /> �❑DISAPPROVAL <br /> ,Authorized Signature Dat <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-0189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> • <br />