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Nebraska Application for Exemption 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 /> Applicants Name Type of Ownership <br /> Mid-Plains Center for Behavioral Healthcare Service, Inc ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 615 N Elm St Hall <br /> ❑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 /> CEO Corrie Edwards,914 Baumann Dr,Grand Island,NE 68803 <br /> CFO Lance McKenney,PO Box 1763,Grand Island,NE 68802 <br /> COO Drew Schreiber,615 N Elm St,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 /> if Newly Purchased <br /> Dodge Braun 2016 SPORT VAN 2C7WDGBG9GR313696 6/24/2016 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑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 /> To pick up clients and transport them to the Crisis Stabilization Unit. To take clients from the If No,give percentage of exempt use: <br /> Crisis Stabilization Unit to the next level of care. To pick up clients in Adams county and <br /> transport them to services needed. q <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 based on race,color,or national origin. <br /> sign -Lent /yOsenfrir CFO 6/29/2016 <br /> here I Authorized Signature Title Date <br /> goer 1l( FOR COUNTY TREASURER RECOMMENDATION ,�/ c �y <br /> PROVAL RECEI O MENTE: ��/—e4—n- ��1i /v' '�Y ?` spa <br /> ❑DISAPPROVAL <br /> JuN 2 g 2016 <br /> Signature of County Treasurer Date <br /> IALI COUNTY_ <br /> TREASURERS S�–OUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND,NEBRASKA <br /> PPROVAL COMMENTS: <br /> ❑DISAPPROVAL ' /�r - <br /> a iii I a�4 / - / <br /> .riz—.• gn:tur • ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.1/277-202(1)(c)and(d),and 60-3,185.and 60-3.169 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.52009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />