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• <br /> --z— Application for Exemption FORM <br /> NeREVENUE <br /> from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> 'To be Instructions your reverse side. <br /> treasurer. <br /> PROPERTY ASSESSMENT _ •Read Inshuetions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Mosaic (308)381-1690 ext. 205 ir Nonprofit <br /> Street or Other Mating Address County Corporation <br /> 2846 Old Fair Rd. Hall ❑Other(speciY): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> See attached <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,N necessary. <br /> Registration Dale or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> If Newly Purchased <br /> Chevrolet 2015 Sedan 1G11C5SL7FE202221 11/20/14 <br /> Chevrolet 2015 Sedan 1G11C5SL8FF206830 11/20/14 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgdcuhuravHorticunural ❑Educational Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist EYES ONO <br /> Transportation of disabled individuals. <br /> n No,give percentage of exempt use: <br /> • <br /> i <br /> Under penalties of law,I declare that I have examined this application and that it ls,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 empl nt based on race,color,or national origin. <br /> sign � Business Manager 11/20/14 <br /> here I Authorized Signature Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> RAPPROVAL RECEIVED COMMENTS: '°' -'tic} '/a:5 77-a0a <br /> ❑DISAPPROVAL <br /> NOV 2 1 2014 -�s�a ofh> //./-/y <br /> /Signature of County Treasurer Date <br /> HALL COUNTY FOR f`OUNTY BOARD OF EQUALIZATION USE ONLY <br /> r rnErMSORcNS OFFICE <br /> GRAND ISLAND.NEBRASKA <br /> "{�APPROVAL COMMENTS: <br /> /A❑V DISAPPROVAL <br /> /31 ,ri <br /> 11 Authorized Signature Date <br /> Nebraska Department or Revenue Authorized by Neb.Rev.Stet 55 77-202(1)(c)and(d).and 60-3.185.and 50-3.tag <br /> 96.263•2006 Rev.8-2011 Supersedes 96-2112008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />