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me.----e- Application for Exemption FORM <br /> Nebraska Depemmenl of Qualifying 457 <br /> REVENUE from Motor VehicleT•Tebofled uru tyt�surer. Organizations <br />' PROPERTY ASSESSMENT •Read Instructions on reverse side. TYPE of Ownership <br /> Applicant's Name <br /> MID PLAINS CENTER FOR BEHAVIORAL HEALTH CARE SERVICES INC ®onppumion <br /> Street or Other Mailing Address HALL <br /> 615 N ELM ST PO BOX 1763 ❑other(specify): <br /> City Stale Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br />• <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code , <br /> jrr p tv/n'G Ed ,-h Oo�/7/x3 c.� 0/s—s/H��� geed z <br /> _COO gefn;t Xs cell 1(e yfG�1nrstc-,vz/TS �s.,diL! ea <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,It necessary. <br /> Registration Date or <br /> Vehicle ID Number Date of Acquisition, <br /> Motor Vehicle Make Model Year BodyType if Newly Purchased <br /> A . 00 for n / g L c`T�irti rlto <br /> �.,.z : -n o W'L'�i �.io.., ��©� , ' . r 711 . <br /> i . , ; A i[ . <br /> Are the motor vehicles used exclusively <br /> Exempt Uses of Motor Vehicle: as indicated? <br /> ❑AgriahurabNorticulWrel ❑Educational ❑Religious 1,4 Charitable ❑Cemetery <br /> YES ❑NO <br /> Give detailed description of yse,including an explanation if multiple use classifications exist: r 5 <br /> to p tkM p nn A "grry Cyan*5 to aril(roe`-1 4/,c4 /di r <br /> I d f I O� C,/r'4• e 5, If No,give percentage of exempt use: <br /> To lagl /yL1N I � ¢s"5 I � 11'Id �Y ! n % <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 <br /> does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign / VP/Cow ii�zc�i� . <br /> here 'Au ooze ignature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> PPROVPL RECEIVED COMMENTS: ,, <br /> ❑DISAPPR)VAL 0/ �, <br /> NOV 2 1 2014 C//��. ,..'/F—'J /-17-z-3 <br /> It Signature of County Treasurer <br /> Date <br /> W�LCUUMTY FOR CO JNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAN <br /> TREASURERS OFFICE <br /> D NEBRA �rrxnENTS: <br /> cc.APPROVAL <br /> ❑DISAPPROVAL Al <br /> l)1,41.1 ! A /� 73 ri 5 <br /> •M •razed ignat: - - ate <br /> Authorized by Nett Rev.Sort.§§77-202(1)(c)and(d),and X3.185,and 803,189 <br /> Nebraska 96-253-2006 0epe v.8- 1f Revenue& me <br /> 93 2532008 Per.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />