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itiz 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 /> HALL COUNTY C/O SENIOR CITIZEN INDUSTRIES, INC. N Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E. 3RD ST HALL ❑Other(specify): <br /> 1 City State Zip Code State Where Incorporated <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 LIST ' <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,N necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> FORD 2015 BUS 1FDFE4FS9FDA23950 06/18/15 <br /> FORD 2015 BUS 1FDFE4FSOFDA23951 06/18/15 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious N Charitable ❑Cemetery <br /> as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> Provide public transportation of the elderly, handicapped,and general public within Hall No,give pt\E V ie l t <br /> If County. <br /> JUL 9 2015 <br /> f L rgUnder penalties of law,I declare that I have examined misapplication and that it is,to the best of my knowledge and be ef,true,comp�H p pFFICE <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-Iistetl�roperXDPIAIg096PJr NO;d4EBRASKA <br /> in membership or employment bas-•on race,color,or national origin. <br /> sign / • . --7S- <br /> her-• Authori ignature j Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> 1PROVAL COMMENTS: <br /> • <br /> ❑DISAPPROVAL <br /> SiJuatore of Coun T 4114 I Date _ {J <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> m APPROVAL COMMENTS: <br /> !❑`DISAPPROVAL <br /> ' on ,. .nature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185.and 60-3,169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> 1 <br />