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Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •TO be filed with your county treasurer. I •Read instructions on reverse side. Applicants Name Type of Ownership PEACE LUTHERAN CHURCH ®Nonprofit Street or Other Mailing Address County Corporation 1710 N NORTH RD HALL []Other(speciry): City State Zip Code State Where Incorporated GRAND ISLAND NE 68803 NEBRASKA IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City.State,Zip Code CHAIRMAN MIKE NELSON,330 SALEM RD,BOELUS,NE 68820 VICE CHAIRMAN ELAINE NELSON, 1120 SAGEWOOD AVE,GRAND ISLAND,NE 68803 SECRETARY RICK HULS,4247 KAYE AVE,GRAND ISLAND,NE 68803 TREASURER BOB BERAN,4238 SUMMER CIR,GRAND ISLAND,NE 68803 DESCRIPTION OF THE MOTOR VEHICLES *Attach an additional sheet,it necessary. Registration Date or Motor Vehicle Make Model Year 6odyType Vehicle ID Number Date of Acquisition, if Newly Purchased MFG ENC TRAILER-4 WH-RED 1991 XT XU 87726 JULY 5,2015 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑AgriculturallHorticuttural ❑Educational ®Religious ❑Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist: l2A �EIVED The trailer will be used to haul equipment and materials used to help members fulfill our If Na,give percentage of exempt use: mission which is to bring the word of Jesus Christ to residents of Grand Island and Hall County. a. Peace Lutheran is a religious organization; b. The trailer will be used exclusively for religious purposes; c. The trailer is not owned or used for financial gain or profit to either JUL 1 0 2015' the owner or users; and d. Peace Lutheran does not discriminate in membership or employment based on race, color, or national origin. TREASURERS OFFICE F� DRANDJSLAND.NEBRASKA 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 also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. . 0 3 VTQ sign 'a�2 � TREASURER V 07-09-2015 here Authorized Signature Title Date FOR COUNTY TREASURER RECOMMENDATION PROVAL COMMENTS: ❑DISAPPROVAL • , r11 I r ,_. : ' _. _ i_ i1 Sig lure of County Tr: rer Da S FOR COUNTY BOARD OF EQUALIZATION USE ONLY *APPROVAL COMMENTS: ❑DISAPPROVAL Authorized Signatur, Date Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)end(d),and 60-3,185,end 60-3,189 96453-2006 Rev.8-2011 Supersedes 94253-2006 ReV.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.