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Application for Exemption FORM <br /> Nebraska Deparlmcnt of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •To be filed with your county treasurer. 457 <br /> •Read instructions on reverse side. <br /> Applicants Name Type of Ownership <br /> Central Nebraska Child Advocacy Center DRI Nonprofit <br /> Street or Other Meiling Address County Corporation <br /> 2335 N.Webb RD Hall ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Tide Name,Address,City,State,Zip Code <br /> MDT coordinator Joste Lindell 2335 N.Webb rd Grand Island Ne 68803 <br /> Lead Forensic Interviewer Amber Alvldrez 2335 N.Weeb Rd.Grand Island NE 68803 <br /> Family Advocate Mallory Zelasney,2335 N.Webb Rd,Grand Island,Ne,68803 <br /> Executive Director Shanie Bookman 2335 N.Webb Rd,Grand Island Ne,68803 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Data of Acquisition, <br /> If Newly Purchased _ <br /> Ford 2002 Ford Focus LX 1FAFP33P02W198469 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious ®Charitable ❑Cemetery <br /> as indicated? <br /> Give detailed description of use,including an explanation it multiple use classifications exist: ®YES ONO <br /> This vehicle is used to transport CNCAC employees to other counties and communities in <br /> Nebraska in order for employees to be present at meetings,attending trainings and/or If No,give percentage of exempt use: <br /> provide trainings to surrounding communities to ensure the appropriate out reach to our <br /> communities member to spread awamess of Child abuse. <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 /> IP <br /> sign "A_ 1nFecim Ex,du\-i Ue Vireckr 12./4/7/5 <br /> here ` thori2ed • ,nature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> Q APPROVAL COMMENTS: -°�'� � J ,"� /`L—' <br /> �t.TCR'F'gS <br /> oJapFFI yG� <br /> ❑DISAPPROVAL ^ X %: <br /> Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> XAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> Au razed ignat 61.42441:21°.at_ <br /> Nebraska Department of Revenue Authorized by Nab.Rev.Star.14 Tr-20211)(c)and(d),and 603.155.and 80.3189 <br /> 96.253-2006 Rev.a-2011 Supersedes 96.263-2006 Rev.6-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />