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�^-�- Application for Exemption FORM <br /> Nebraska Depanment 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 /> Applicant's Name Type of Ownership <br /> GRAND ISLAND DIVE AND RESCUE TEAM ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3107 WOOD RIDGE BLVD -HALL <br /> 0 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,Stare,Zip Code <br /> PRESIDENT DAVE LEMBURG 1123 E NEBRASKA AVE GRAND ISLAND NE 68801 <br /> VICE PRESIDENT TIM CZAPLEWSKI 510 E 1ST ST GRAND ISLAND NE 68801 <br /> SECRETARY JACK WELCH 4116 W FAIDLEY AVE GRAND ISLAND NE 68803 <br /> TREASURER PAT LONERGAN 3107 WOODRIDGE BLVD GRAND ISLAND NE 68801 <br /> DESCRIPTION OFTHEMOTOR VEHICLES <br /> •Attach an additional sheet,N necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> WELL CARGO .2003 UTILITY TRAILER 1WC200F2831103907 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> as <br /> AgdculturavHorticultural []Educational Q Religious ®Charitable 0 Cemetery indi ated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: ®YFS ❑NO <br /> THIS TRAILER IS USED TO TRANSPORT DIVE RESCUE EQUIPMENT FROM RURAL <br /> If No,give percentage of exempt use: <br /> FIRE STATION IN GRAND ISLAND NE TO ANY RELATED ACCIDENT SCENE IN AND <br /> AROUND GRAND ISLAND NE. MAY ALSO BE SUED FOR WATER SAFETY TRAINING <br /> CLASSES ALSO IN GRAND ISLAND AND OTHER CLOSE TOWNS. <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 1 am duly authorized t�o^sii�yyygguuunn this exemption application,and that the organization owning the above-listed properly does not discriminate <br /> in membership •gment/� e,color,or national origin. <br /> sign � T t-,R7S2-ec /z-7G -71 <br /> here ,Aulhoriz=• • Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> �'240.2-,[ PROrAL RECEIVED COMMENTS: � ' /04--; �N-9C- <br /> DISAPPROVAL _ <br /> DEC 162014 /-efir---/5� <br /> • Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> -TREASURE ALS OIPlCl <br /> laAPPROVAL ISLAND.NEBRASKA <br /> APPROVAL COMMENTS: <br /> DISAPPROVAL <br /> Afiar <br /> Authonzed Signature Date` <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 603.185,and 603.189 <br /> 96-253.2006 Rev.8-2011 Supersedes 96-2532006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />