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��— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Mid-Plains Center for Behavioral Healthcare Services, Inc. Nonprofit <br /> Street or Other Mailing Address County Corpo tion <br /> PC)Box 1763 Hall ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> CEO/President Carrie Edwards,615 N Elm St,Grand Island,NE,68801 <br /> COONP of Operations _ Bernie Hascall,615 N Elm St,Grand Island,NE,68801 <br /> CFONP of Finance Lance McKenney,615 N Elm St,Grand Island,NE,68801 <br /> VP of Human Resource Andrew Schrieber,615 N Elm St,Grand Island,NE,88801 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Pontiac 2005 4 Door Sedan 1G2NE52EX5M146407 2116/15 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural 111 Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> This vehicle will transport our YCS supervisor to the various locations that we have YCS No,give percentage of exempt use: <br /> II centers. <br /> a <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 Lam` (VCr. CFONPofFinance 3/5/15 <br /> here Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVEDLOMMEIITS: . ,� „ra"—/ n/ssi,51. ' 77 4'o <br /> ❑DISAPPROVAL <br /> MAR 5 2015 4 �� <br /> Q°o k__)v' <br /> i1 <br /> Signature- Treasurer Date <br /> TREAsr Yisu•L pros rip COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND,NEBRASKA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> /IA/ L <br /> Art: //•r�orized 'enatu ate� <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d).and 60-3,185,and 60-3.189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96.253-2006 Rev.5.2009 <br />• PLEASE RETAIN A COPY FOR YOUR RECORDS. • <br />• <br />• <br />