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020 / 7 <br /> Application for Exemption <br /> Nebraska Depsnment of 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 /> Applicant's Name Type of Ownership <br /> GRAND ISLAND AREA HABITAT FOR HUMANITY INC ❑ Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> ❑Other(specify): <br /> City State • Zip Code State Where Incorporated <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <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 /> it Newly Purchased <br /> GMC 1996 CUTAWAY VAN 6350 1GDJG31K7TF501630 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturavHorticultural ❑Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: OYES ❑NO <br /> • <br /> Se_e_ cz -a ck ed2- <br /> _t — l 3r p G �'✓ <br /> 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 stn 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 /> here ,Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION. <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> Signature of County Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> 0 Authorized Signature Date <br /> Nebraska Department of Resent* Authorized by Neb.Rev.Slat§§77-202(t)(c)and(It and 60-3,185,and 60-x189 <br /> 96.253-2006 Rev 8-2011 Supersedes 96-253-2006 Re..5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />