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•aka —z— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •to be n ed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Heartland United Way, Inc ® Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1441 N Webb Rd Hall <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> President,CEO Karen Rathke,3836 Meadowlark Cir,Grand Island,NE 68803 <br /> Board Chairman Todd Price,1104 W Division St,Grand Island,NE 68801 <br /> Board Vice Chair Kelly Henry,3024 Bighorn PI,Grand Island,NE 68803 <br /> Board Treasurer Wade Jarvi,309 Buffalo Grass,Grand Island,NE 68803 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> 'Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Ford 2010 F150 1FTFX1CV6AKA9468 S-4 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑ <br /> Agricultural/Horticultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use.including an explanation if multiple use classifications exist: k-vj YES ❑NO <br /> The truck will be used for United Way programs, fundraisers and events. Several programs <br /> involve hauling toys,food and household furniture. The truck will also be used to distribute No,give percentage of exempt use: <br /> United Way program and campaign materials to community partners located in Hall, <br /> Hamilton, Howard and Merrick Counties. The truck will also be used by staff to travel to <br /> United Way meetings and trainings locally,statewide and out of state. <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 members"or empb i ent based on race,color,or national origin. <br /> 9 � t <br /> sign �Inla � President, Chftf Executive Officer 05-04-2016 <br /> here 1 Auth ri ed Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION �}/- <br /> •APPROv L RECEIVED CUMI®ENTS:.x�/-i 7' <br /> ❑DISAPPF OVAL <br /> MAY 4 11 C <br /> 2O 1u l/Signat re of ounty Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE • <br /> NPPROWEL GRAND ISLAND,NEBRASK,4 roomENTS: <br /> ❑DISAPPROVAL <br /> Au it•Sign-ir,1far • uate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d).and 603,185,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 />