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02o1-7 <br /> Nebraska Department of Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be liled with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicants Name <br /> Type of Ownership <br /> HEARTLAND UNITED WAY, INC <br /> 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 Clr,Grand Island,NE 68803 <br /> Board Chairman Todd Price,1104 W Division St,Grand Island,NE 68801 <br /> Board Vice Chair Kelly Henry,3024 Bighom 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 /> Motor Vehicle Make Model Year BodyType <br /> Registration Acui Date n, <br /> y ype VehiUe ID Number bete of Ration, <br /> If Newly Purchased <br /> FORD 2010 F150 _ 1FTFXZICV6AKA9468 <br /> HAULMARK 2014 TRAILER 575P81420EH264757 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgnculturalMorticultural ❑Educational ❑Religious ®Charitable 111 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> Both the pick up and trailer will be used for United Way programs, fundraisers and events. <br /> Several programs involve hauling toys,food and household furniture. They are used-for If No.give percentage of exempt use: <br /> hauling program items to community partners located in Hall, Hamilton, Howard and Merrick <br /> counties. They are also used by staff to travel to United Way functions that require hauling <br /> event items locally,statewide and out of state. <br /> Con\c Kaleyr■ or & u 3c 3ssa-as- c <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 1 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 �I / / President/Chief Executive Officer 12-8-16 <br /> here ('Autho ed Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> (APPROVAL RECEIVEDMMENTt: `z1""MM id2W /7.SS: 7 <br /> ❑.DISAPPROVAL <br /> DEC 1 2 2010 c o(6--e-�.� /a <br /> I°Sign <br /> ature of tyTreasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL CAJUN I Y <br /> TREASURERS OFFICE <br /> ❑APPROVAL GRAND ISLAND,NEElltersAincit S: <br /> El DISAPPROVAL - <br /> /' <br /> • <br /> /e ts" i0 77 <br /> Authorized Signa r" Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev,Stat.§§T1-202(1)(c)and(d),and 80.3.1e5,and 603.189 <br /> 95-253-2006 Rev.8-2011 Supersedes 96-253'2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />