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h017 <br /> aften..-----z-- Application for Exemption FORM <br /> Nebraska Department d) <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •TO be filed with your county treasurer. 457 <br /> •Read Instructions on reverse side. <br /> Applicant's Name <br /> Type of Ownership <br /> HOPE HARBOR ®Nonprofit <br /> Street or Other Wang Address County Corporation <br /> 615 W FIRST ST PO BOX 1544 HALL t>uter(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title 44114 Na Add ss,City,State,Zip Code <br /> - �- <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make I Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> If Newly Purchased <br /> CHEW 2006 UPLANDER VAN 16NDY33L06D163945 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturalMorlicu)ana) ❑Educational ❑Religious 1Charrrabfe ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: EYES LINO <br /> ''r7cP )` `-) t'•4 ••1 3 Y -rY•m-..n,�. a P.t ,- t • .i '\ `?..-y., 1.4 , .T'YF ..7 ?9 ;q/?t'Y1 <br /> �; /1 If No,give percentage of exempt use: <br /> Gnair ; -f-a ;It 0rgakl .4 �C24 ;mS; --rrali-ASt90( ! IA 9 % <br /> r / ri 4 S -&r,ro -Ike._ LuAC>-21 e_ ?Ps s A-241 e r s (-?-ra r.i 4;6k1 a_(� <br /> fr v+"-P r ty to r e.,t Sr.L.K. rs" <br /> Under penalties of law,I declare that I have examined this application and that it is,to me 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 (/(44„1/4,_, C� <br /> here III,AIM ed Sgnature2c -et,\eeve. rf hoard men 69r //-251 -/ (4, <br /> Date <br /> I FOR COUNTY TREASURER RECOMMENDATION <br /> I9nPPROVAL RECEIVEDOMMErTS: e"/-2-7n2-Ale <br /> /2"--1 "PCS: 77-act2 <br /> ❑DISAPPROVAL <br /> DEC 1 ?"'o C �Ap/� '`— <br /> /Signature of County Treasurer Date <br /> _ HAL6ZUN rY <br /> ,F.OLR COUN-Y BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND NEBRASK;:, <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> l <br /> 1-7 D 77 <br /> thorized innate 1e ' Date <br /> Nebraska Department or Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(N.and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.82011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />