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et.---e__- Application for Exemption FORM <br /> f, ska()apartment of <br /> REVENUE from MotorVehicleTaxes 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 /> SENIOR CITIZENS INDUSTRIES ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> I 304 E THIRD ST HALL ❑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 /> Tale 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 /> Meter Vehicle Make I Model Year BotlyTypo Vehicle ID Number Dato of Acquisition, <br /> If Newly Purchased <br /> Kia Sedona 2006 van KNDMB23366075648 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> El ttu Agricu alMorticultural ❑Educational El Religious E Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> Provide delivery of Meals on Wheels within Hall County <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 than am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership of employment based on race,color,or national origin. <br /> sign .r -.i/ ; ���e /I oZo-lz/ <br /> here Au oozed Signature / Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION I <br /> aPPROVA. RECEIVED COM NTS .167-tentAt'gaj �c5 5, 7 mac, <br /> 1 ❑DISAPPROVAL _ <br /> NOV 2 D 2014 isgntr--my Treasurer D/-cr-/.�' <br /> FOR COL NTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE <br /> tI.APPROVAI GRAND ISLAND,NEBRASKAnktuFNTS: <br /> ❑DISAPPROVAL <br /> /; 2_,� /-/5-45 <br /> Aul'•rized Sign?ie •r pr " r Date <br />• <br /> Nebraska Department of Revenue Authorized by Neb.Rau Stat.§§77-202(1)(c)and td),and 603,185,and 603,189 <br /> 96-2532008 Rev.8-2011 Supersedes 96-253-2006 Rev..5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />