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Z-0) & <br /> Application for Exemption FORM <br /> Nebraska[warm eM of <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 /> SENIOR CITIZENS INDUSTRIES, INC. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E THIRD ST HALL 0 Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE 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 /> B Newly Purchased <br />• Dodge Grand Caravan 2010 van 204RN5DX5AR192152 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 0 Agricultural/Horticultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES NO <br /> Provide delivery of Meals on Wheels within Hall County. No,give percentage of exempt use: <br /> If 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 /> sn <br /> he a %►.1 44 / , , &xe hdi tie Qr rtc.Ir //-36•-IC <br /> thorized Signature / Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> ErAPPROVML RECEIVED COM RENTS: erla -ry il"j ,a' A/5. X77 aOa <br /> • <br /> T <br /> 0 DISAPPROVAL . <br /> NOV 3 0 2015 tor9 o -O • <br /> Signature of County Treasurer Date <br /> A ► FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TRFHS <br /> HALL LL FRS COO n t7FF1rJr OU <br /> gAPPROVAL ISLAND,NEBRASKA • <br /> M APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> / <br /> .I <br /> T Zed S'r a=lure ate <br /> Nebraska Department of Reven00 Authorized by No Rev.Slat.§§77-202(1)(e)and(CI,and 60-3,185,and 663.189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2039 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />