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261,5 <br /> — Application for Exemption FORM <br /> Nebraska Department of <br /> REVENREVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> UE •To be filed with your county treasurer. <br /> minammil •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> 1 MOSAIC ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2846 OLD FAIR RD HALL ❑Other(speedy): <br /> City State Zip Code Slate Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> S eA A -....GLcJ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor vehicle Make I Model Year BodyType 1 Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> ea_ R 'ttcc_L <br /> Exempt Uses of Motor Vehicle: �--/ Are the motor vehicles used exclusively <br /> ❑AgriailturabHorficultuml ❑Educational KI Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: [grES ❑NO <br /> I <br /> TrcW S�--4a.4 �: 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 beliel,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 B >=:N� $ m fr tt- (a ( 4 <br /> here Authorized Signature Title -erg_.343( (6p�•t-�aQJ <br /> FOR COUNTYTREASURER RECOMMENDATION I`-' L C� <br /> Q'APPROV ENTS: tC'�" 7- /—�J Al. 9'• .4a 7.7-ao.e <br /> ❑DISAPP VAL RECEIVED <br /> �p7�/�7jA,��� `�`/7, <br /> NOV 1 9 2014 I'SignatureotCoumyTrea _4 /e8 <br /> FOR C NTY BOARD OF EQUALIZATION USE ONLY <br /> '�/ TREA RERS FFICE <br /> HALL COUNTY <br /> 7(APPRO L QRgND ISLAND,NEBFiASKACOM ENTS: <br /> '�❑`DISAPPROVAL _iI_ w <br /> i ta /7 I -1 g-stis <br /> • 'on -*rrg at re Date <br /> Nebraska Department of Revenue Authorized by Neb.Rey.Stat.SS 77-202111(c)and(d).and 80-3,185.and 80.31a9 <br /> 9e-253-2008 Ray.8.2011 S.persedes 98-253-2008 Rey.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />