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,oil <br /> aten_--z_, Application for Exemption FORM <br /> Nebraska Det.admem of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be filed with your county treasure <br /> •Read instructions on reverse side. <br /> Applicant's Name <br /> Type of Ownership <br /> GOOD SAMARITAN SOCIETY GRAND ISLAND VILLAGE Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4075 TIMBERLINE ST HALL <br /> ❑Other(specify): <br /> City State Zp Code State Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tide Name,Address,City,State,Zip Code <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> *Attach an additional sheet,If necessary, <br /> Motor Vehicle Make I Model Year 9odyTypa I Vehicle ID Number Registration Date or Dale of Acquisition. <br /> if Newly Purchased <br /> FORD 2003 W <br /> _ UBDSTAR 2FMZA51443BB51330 <br /> FORD 2010 AMERITRANS(BUS) 1FDWE3FLIADA61698 <br /> DODGE 2012 _ GRAND CARAVAN 2C4RDGBGXCR298624 <br /> DODGE 2001 RAM SHORT BED 1500 1B7HF16Z81S707690 <br /> FORD 2013 STAR TRANS E 450 8 1FDFE4S2DDA26721 <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,AIL- in including an explanation if multiple use classifications exist: IdI YES ❑NO <br /> 144 If No,give percentage of exempt use: <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 <br /> ?muour+ � 1Te, YYl -11-12,2A <br /> here Amnon- Signature Title ) • Date <br /> FOR COUNTY TREASURER RECOMMENDATION I <br /> PPROV.L RECEIVED COMP ENTS: 4,a,c.c r77 °'c`2 <br /> ❑DISAPPROVAL _ <br /> DEC 1 2 2016 � '�'�P /P-c'er-�� <br /> Signature of County Treasurer Date <br /> FOR CO JNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY - <br /> TREASURERS OFFICE <br /> ❑APPROVAL GRAND ISLAND,NEBRASKtQ WENTS: <br /> ❑DISAPPROVAL <br /> e.,:— .- 7S a1 .. , -/' /- 9 /7 <br /> thorized Signs' - bale <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)4c)and(d),and 843,185,and 60-3,189 <br /> 96-253.2006 Rev.8-2011 Supersedes 98-253-2006 Rev.5.2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />