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wi^--z- 1 Application for Exemption 2) ( co FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •Read instructions on reverse side. Applicant's Name Type of Ownership MID PLAINS CENTER FOR BEHAVIORAL HEALTH SERVICES INC ®Nonprofit Street or Other Mailing Address County Corporation 615 N ELM ST PO BOX 1763 HALL ❑Other(specify): City State Zip Code State Where Incorporated GRAND ISLAND NE 68802 NE IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,,Zip Code /� Lt 0 C.Orn.c Cpw4r4S (q�y+�5 it 14; I dr r/[J t53 — ( F6 t-AticcI C4nnr1/ Peen�. L7 1t3 en-gbd--'Slr� adU,�/ 'ilol l 00 Or t.0 sc.',H .1.120.— (G1 lve ., c-i`- 6- „d-flJti4d NE' °/ DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,if necessary. Motor Vehicle Make Model Year Body Type I Vehicle ID Number Registration Date or Date of Acquisition, ,�y�,, / ( � .mil / �,�—•If Newly Purchased _ 'Ford P 2/.-0 Qa-40.7 1 36s t71 G.GK LP f 5Af I I�EL2816 0/9/IJ Fol^ G3h`G q y - VA 55 L ii� gtC�l t� 177r pe �}"�'. y .-yhdc4-., vor � 3 I/hh 7: Y`135-3Xz ;9z tl!/ir- - �0 gr. y A-o,Qn -/A v4 , 7_td f - 1�. .2.B 76 lit 3SY/A 1I3 Y�' jJ// j/5- - Poh}-ictC 4+rc1nN rt4K't ZOO 6- 5 -CG/a_h 16 SLf?X riti lt16EO71(lci/4` Exempt Uses of Motor Vehicle: Are the motor^Ishicles used exclusively ❑Agricultural/Horticultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? Give detailed description of use.including an explanation if multiple use classifications exist: [YES ❑NO To P,'c(yp 4141.-i"5/7-0 t CIh 1.)"15 /-0 $15%°'+x55, P2 /h 5,,,a,,..-'t F4l>, /. Yo �� If No,give percentage of exempt use irOro one I've,-4. 5,Yc / c ble/6u,: IO p lc-1<ceiri4c(,m'.'es lk?dee s q °'soya 5how. Under penalties of law,I declare that I have examined this application and that d is,to the best of my knowledge and belief,true.complete,and correct.I also declare that 1 am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. sign c r6 /1//,//s- 1 here Authorized Signature Title Date psi.``aa++y�� err.Fonfi6Yd'TY TREEASURERR RECOMMENDATION J E APPROVAL —RECEIVED MMENA4: .Cs�' 4.-71 �1tc /Y-�.` /f 77_ . Zy.TRpgs o`�$kt G% 0 DISAPPROVAL NOV ; 13 2015 � � HALL COUNTY /Signature of County Treasurer Date TREASURERS QFFICE GRAND ISLAND,N S JI Mfl BOARD OF EQUALIZATION USE ONLY AAPPROVAL COMMENTS: ❑DISAPPROVAL c/_/� AN izc Signature 0-� Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 603,185,and 60.3,189 i 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.