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+^� Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> maanzigza •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Crisis Center, Inc. <br /> ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2251 N Webb Rd. PO Box 5885 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 /> Board President Jessica Hoback 1415 W Charles St. Grand Island,NE 68801 <br /> Board Vice President Barb Ernst 1604 L St. Aurora,NE 68818 <br /> Board Secretary Lynelle Homolka 1475 Omsby Rd. Central City,NE 68826 <br /> Board Treasurer Monte Hack 204 N Walnut Grand Island,NE 68801 <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 /> N Newly Purchased <br /> Ford 2014 Fusion SE FWD 3FA6POH99ER169634 2/15/16 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticuaural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> This vehicle will be utilized to transport victims of domestic violence and sexual assault when <br /> If No,give percentage of exempt use: <br /> safety is in place. It will be used in our county as well as our outreach counties when needed <br /> for victim appointments and assistance. The vehicle will also be used to transport Crisis <br /> Center staff for trainings,education and prevention presentations,and meeting with other <br /> human service agencies. <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 tebased on race,color,or national origin. <br />• sign }K Executive Director 3/1/16 <br /> here I Authorized Signature w 1 Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> PAP ROVAL RECEIVED COMMENTS: , PY 42 s 'f77 Q42 <br /> ❑DISAPPROVAL <br /> MAR 2 2016 �/ � 0[-4cia e 3-/G <br /> Signature of My Treasurer Date <br /> HALL COUNTY FOR COL NTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> %APPROVAL - MWENT& <br /> ❑DISAPPROVAL a p <br /> /L./��� /' i/j Je/ /I4P <br /> p <br /> Nebraska Department of Revenue Authorized by Neb.Rev.SIaL§§77-202(1)(c)and(d),and 603,185,and 603.189 <br /> 98-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />