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Nebraska amen,ar[..-- Application for Exemption t9L 7 V' FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> atm •To be filed with your county treasurer. 457 <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> GOODWILL INDUSTRIES OF GREATER NEBRASKA INC <br /> ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1804 S EDDY ST PO BOX 1863 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 /> Ft.-ajrsc a cjr eA <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> i •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 /> 1 n. `� ` if Newly Purchased <br /> Ter A Ao-elua. <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> I ❑AgriculturaVHorticuitural fri Educational ❑Religious ❑charitable ❑Cemetery as indicated? <br /> Give detailed description of use,Including an explanation 1If.multiple use classifications exist: �5@D BYES ONO <br /> Llise. . Soy-pickt tap outd Ao,jt &a{nomc c.\te.njt. A\30, <br /> S I..epc r4 04. G\l a c a,sc\V tic.. aryl,��Pi k arm If No,give percentage of exempt use: <br /> "tP.Q t.a- h4.!.SI A oc (i *a A-t.c n 3 4%4- Su fpoit ou r-di •u•h r <br /> f'royra.KS . <br /> Cane Peroo-n; rb SPeck, &%-A84--rrtLX 14 ) <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 (� � "� & C: 1 \ �‘a,k5 <br /> here Authorized Signature The Date <br /> FOR COUNTY TREASURER RECOMMENDATION I <br /> f./a'yV " c - X1/4=. . ��` - '"<C_, <br /> [•�APPROVA_ Be*MENTS: �� <br /> RECEDED °J�`Ott.-aa <br /> ❑ DISAPPROVAL <br /> S <br /> , O � R <br /> O.Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> MALL(.UUN t Y <br /> TREASURERS OFFICE <br /> GRAND ISLAND NEBRASKA <br /> 0APPROVAL COMMENTS: <br /> ❑ DISAPPROVAL .,/ <br /> /i:,JI! �`_ _ %//L/I / / <br /> A!'.rize• S nature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat§3 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 />