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mt ° -- Application for Exemption <br /> Nebraska Department or 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 /> MID NEBRASKA INDIVIDUAL SERVICES ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> i 2536 CARLETON AVE HALL Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> ( ka_, r rvA4-en. T Ye-t. I�.le-A PO px 134 G; hbon ,i) 6 flail <br /> Vice rim a;rm0-n. Slade BOO-Ink, IV St P0� R4 '5rUba A) Z- 6 88T2 <br /> ,Sec / rrecrvsocrcr Alle-a, CetY aofl_ K sf Ord (/E 68gGa. <br /> C Eo D)a..nt Ca ,elott( Al& A) Oen0er acts'clines 4--)E C $�fo <br /> DESCRIPTION OFTHE MOTOR VEHICLES J <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make I Model Year I - Body Type I Vehicle ID Number ' Date of Acquisition, <br /> It Newly Purchased <br /> Ste. a 6-1-toezL 1 s1 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> Ill Agricultural/Horticultural 0 Educational ❑Religious ®Chartable 0 Cemetery as Indicated? <br /> Give detailed description of use,Including an explanation if multiple use classifications exist: IYES 0 NO <br /> rG_an.sPoe* de-ye (of m .s*acl(1 6f 5d~t9 ' " If No,give percentage of exempt use: <br /> 1 in d, { u , cis ld.c,l5 an.L provEcric sero cc5 % <br /> e .ar terP a , - . <br /> Under penalties of law,I declare that I have examined this application and thai 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 /> 3P - 3gs --s77s <br /> sign FA - e_I.A.5-ea vl /fret. Or ✓eci-L.-- ; 1 J 131 is <br /> here Authorized Signature Title Date <br /> FOR <br /> COUNTYTREASURE RRE COMMENDATION <br /> „ EC <br /> PPROVAL R rE1% E OMMNTS: / ,-r /24„,___ <br /> /14,-;:c.:•-„, -----77-----77- a-,0, •A,.TRErdO <br /> I:DISAPPROVA cr eiCtle <br /> NOV' ' 8 2715 �- d t _ /9-/-5- -/s` <br /> Iiiii Signature of County Treasurer Date <br /> HALL COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> p rcL,,5URrRO OFr,CE <br /> GRAND ISLAND,NEBRASKA <br /> filAPPROVAL COMMENTS: <br /> o DISAPPROVAL ' / <br /> /Ai 4!,,t. A�a9,�15 <br /> A 1Crized S P. 'an ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat§§77-202f 18c)and Ed),and 60-3,185,and 60-3,189 <br /> 96253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />