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een.----e__- ' Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor VehlcleTaxes 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 /> Mosaic ®Nonprofit <br />• Street or Other Mailing Address County Corporation <br /> 2846 Old Fair Rd. Hall ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,Slate,Zip Code <br /> See attached <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number. Date of Acquisition, <br /> if Newly Purchased <br /> Dodge 2015 Van VIN 2C7WDGBGOFR603906 01/05/2015 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturatlHorlicultural ❑Educational ®Religious ❑Charitable ❑Cemetery as indicated? <br /> i <br /> YES NO <br /> Give detailed description of use,including an explanation d multiple use classifications exist: ® ❑ <br /> Transportation of disabled individuals If No,give percentage of exempt use: <br /> % I <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 /> w <br /> sign ate Business Manager 01/05/2015 <br /> here II,Authorized Signet'ii, Title Date <br />• FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVED COMMENTS: - A/5,-5 "77— .04' <br /> ❑DISAPPRO 'AL <br /> JAN 9 2015 , 3Q¢-razIL /- 9--/5" <br /> I•Signatu o C my Treasurer Date <br /> MALI r,nuwry FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND NEBRASKA <br /> APPROVAL ' COMMENTS: <br /> El DISAPPROVAL �� �� / <br /> /� / 5 <br /> /ho / sAC al , /--��i TitlJ� <br /> �'honz=•S., ' Date <br />• Nebraska Department of Revenue Authorized by Neb.Rev.Stat§§77-202(1)(c)and(d),and 60-3,185,and 80-8189 <br />• 98.253-2008 Rev.8-2011 Supersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />