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• <br /> ,avet---e..._ Application for Exemption FORM <br /> Nebraska Depamment 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 /> Applicants Name Type of Ownership <br /> HALL COUNTY CIO 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 Stake Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> If Newly Purchased <br /> ** see attached list <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> III AgriculturaVHorticulWal ❑Educational ❑Religious Diii Charitable III Cemetery as indicated? <br /> GNe detailed description of use,including an explanation if multiple use classifications exist: EYES ❑NO <br /> Provide public transportation of the elderly, handicapped, and If No,give percentage of exempt use: <br /> general public within Hall County. T00T % <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 dedare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does nm discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign �� , <br /> is_ . _.�i• 4. ,L ,I. //-A-0—u`I <br /> here Sig m` Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVA.. RECEIVED COMMCNTS:^ . A 4/.15:17. " 7 .10Z <br /> ❑DISAPPROVAL <br /> NOV2 D ����� /�-/� <br /> 2014 i1 Signature of unty Treasurer Date <br /> s umrouN7V FOR court BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE • <br /> GRAND ISLAND,NEBRASKA <br /> APPROVAL CLTMMENTS: <br /> ❑ DISAPPROVAL /.� / <br /> /Art g �� Date 7—7/5 thodzed ••nature <br /> •Nebraska Department of Revenue Authorized by Net.Rev.Slat.S§T7-202(1)(c)and(d),and 603,185,and 603,189 <br /> 96-253-2008 Rev.6-2011 Supersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />