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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 filed 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 Corporation <br /> PO Box 1763 Hall <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68802-1763 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> CEO Corrie Edwards,914 Baumann Dr,Grand Island,NE 68803 <br /> CFO Lance McKenney,PO Box 1763,Grand Island, NE 68802 <br /> COO Drew Schreiber,615 N Elm St,Grand Island,NE 68801 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if 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 F250 2008 Pickup 1FTSX21528EE22845 11/9/2015 <br /> • <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaLMorticultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> It will be used to pick up and transport supplies from and to offices as well as remove snow. No,give percentage of exempt use: <br /> If 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 ✓ CFO 11/18/2015 <br /> here Authorized Signature - Tale Date <br /> FfR COUNTY TREASURER RECOMMENDATION Al <br /> [✓]APPROVAL 1I E�'+ Ei1ED COMM_NTS: £'Y"t , 4 4 c 't Weoa <br /> ❑DISAPPROVAL 1 B 2015 <br /> NOV y L � J <br /> HAL{R,QOUNTY <br /> Signet e f nty�rer Date <br /> TRSSGAPIaRDS-NEB 1 COU ITV BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> DISAPPROVAL <br /> 'brae:. ": re ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)and Id),and 60-3,105,and 90.3,199 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-2532006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />