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a 15 <br /> eitiz_ 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 /> Applicant's Name Type of Ownership <br /> HEARTLAND LUTHERN HIGH SCHOOL ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 3900 W HUSKER HWY 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,Slate,Zip Code <br /> CHAIR GINA SUCHANEK 2204 VIKING RD GRAND ISLAND NE 68803 <br /> VICE-CHAIR SHAWN MESSERSMITH 2916 W NORTH FRONT ST GRAND ISLAND NE 68803 <br /> SECRETARY JANET HOLLMAN 3911 MARY LN GRAND ISLAND NE 68803 <br /> TREASURER TED BADER 736 6TH AVE ST PAUL NE 68673 <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 /> INTERNATIONAL 1999 BUS 1HVBJABN6XA021230 <br /> FORS ■ e„ <br /> GM6 ---VW/ _ . _ _ - - .- •-•. <br /> CHEVROLET 1999 SUBURBAN 3GNEC16R9XG210246 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturavHorticultural ©Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 1,2 YES ❑NO <br /> TRANSPORTING STUDENTS TO AND FROM ACTIVITIES. <br /> 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 properly does not dscriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign Li—. BOOKEEPER 12-15.14 <br /> here i thorized Signal,e / Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> [+ PROVAL RECEIVED COMM :NTS: 'x' 9 77-gee,„„2 <br /> ❑DISAPPRC'dAL <br /> DEC 1 2014 c flV /8=�-� <br /> /Signature of County Treasurer Date <br /> HALL COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND.NEBRASKA <br /> APPROVAL t,I911CIENTS: <br /> ❑DISAPPROVAL /r ,/ <br /> f/ / <br /> I � <br /> Au hwiz=• Signature - Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.$§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />