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es,„_ Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> HOPE HARBOR INC ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 610 W DIVISION ST PO BOX 1544 HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title , Address,City,State,Zip Code <br /> IIPI P t • lett er' 11 _ - P' , ' L, t •r, , - , 0 <br /> w n f 6 r Arin"rftt t51111911fIS,88•o <br /> ttlIK 17i - x"1[1' A a-T l!'StVill <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 I Vehicle ID Number Cabot Acquisition, <br /> it New Purchased <br /> M5iR1 trflintli o , u [ I1/7TLft tu11TP. s, ....• • ,, 0 a <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculWmlMomailtural ❑Educational Ill Religious Charitable ❑Cemetery as indite ? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ES ❑NO <br /> (Ilse 1i2�i(�f Apr log/ N�Ov+f lesslC 4Ah S1UC�^ QS pg. Ihi up 10 014 5/ If No,give percentage of exempt use: <br /> 1 rahS�Qar 1 w C1je,n�5 +0 1Dkltr 4PPpi� h,e$5� ,0 tD ( ;,,ui„� — % <br /> eit4 'o-t "krtth,1C Q+c <br /> 1'/ <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 /> sig n acitfri 9491, r XPfkvo ,rector 1-la-aoiy <br /> here ■Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> K PROV Fb RECEIVED COMAENTS: r <br /> �S 77—c?0Q <br /> ❑DISAPPVAL <br /> NOV 1 4 2014 ( � <br /> Signature Treasurer Date <br />• FOR CO MTV BOARD OF EQUALIZATION USE ONLY <br /> H/,LL COUNTY <br /> TREASURERS OFFICE <br /> 1i]APPROVAL GRAND ISLANDS NEBRASNFCryy.IENTS: <br /> ❑DISAPPROVAL / <br /> /, orized S.rat ;T Date <br /> •Nebraska Department of Reverie Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 80-3,169 <br /> 96-253-2006 Rtv.8-2011 Supersedes 96-253-2We Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />