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�^—L– 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 /> HALL CO CIO SENIOR CITIZEN INDUSTRIES, INC. <br /> Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E. 3RD ST <br /> ❑Other(specify): <br /> City Stale Zip Code State Where Incorporated <br /> (specify): <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> "see attached** <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,H necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number • Date of Acquisition, <br /> if Newly Purchased <br /> • <br /> Ford 2014 Bus IFDFE4FS9E0A78770 12/10/2014 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious [g]Charitable ❑Cemetery as Indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: N YES ❑NO <br /> Provide public transportation of the elderly, handicapped,and general public within Hall No,give percentage of exempt use: <br /> County. <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 /> sign .` 's--t Executive Director 12/17/2014 <br /> her- -Authorized Signature ` / Title Date <br /> RECEiIf �rvrr itEASUR/ ER RECOMMENDATION� A,, or.7 7'�Oa <br /> R tPROVAL COMMENTS: tr/ tai- <br /> ❑DISAPPROVAL DEC 1 7 2014 <br /> ( g)1 /-0? <br /> HALL COUNTY it;ignature of nty Treasurer Date <br /> TRGPS'-'°.GRS OwflC* <br /> GRAND ISLANDAIY BOARD OF EQUALIZATION USE ONLY <br /> ��n APPROVAL COMMENTS: <br /> ❑DISAPPROVAL 4 <br /> Aivirshancarapyi <br /> Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1Nc)and(d).and 603.185,and 803,188 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />