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c'O / Cj <br /> Nebraska---- Application for Exemption FORM <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 /> HALL COUNTY CIO SENIOR CITIZENS INDUSTRIES, INC. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E THIRD ST HALL ❑Other(specify): <br /> 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,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 /> "SEE ATTACHED LIST" <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricukural/Homcultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 4 YES ❑NO <br />• <br /> Provide public transportation of the elderly, handicapped, and general public within Hall No,give percentage of exempt use: <br /> If County. <br /> % <br />• <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 /> if <br /> sign / _ <br /> 9 e- b ;r eckr _36 S <br /> here q•horized Signature Title Date <br /> Tp{yq_Fr+ �)/ ran•OOUITY TREASURER RECOMMENDATION J �` <br /> APPROVAL RECEIVED <br /> ED MMENrS: '��-2,Pnn1J[y2� !,tit-- ///, y.`-✓. 7I- Sen.? <br /> ❑ DISAPPROVAL NOV 3 0 201.5 !!! ___)))--0-5:5;>0 /r/''�^ - <br /> HALL COUNTY 'Signature of County Treasurer Date <br /> ThttnSu RERS OFf <br /> fiRAND ISI AND gQUNTY BOARD OF EQUALIZATION USE ONLY <br /> %APPROVAL COMMENTS: <br /> ❑DISAPPROVAL / <br /> sf'iiirsat �ay/?c'C <br /> Aur!ized Si...t IT:_r- ate <br /> Nebraska Department of Revenue Authorized by Nad Rev.Stat.§§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 />