Laserfiche WebLink
ao , 7 <br /> „�akaDor Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 45 7 <br /> •TO be flied with your county treasurer. <br /> offlaurgEn <br /> •Read Instructions on reverse side. <br /> Applicant's Name <br /> Type of Ownership <br />• <br /> MID-NEBRASKA INDIVIDUAL SERVICES ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2536 CARLETON AVE HALL <br /> ❑Other(specify): <br /> City State Zip Code Stale Where Incorporated <br /> GRAND ISLAND NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name.Address,City,Slate,Zip Code <br /> Chair-rti.an 'VAR l'6 e14 Pa BIC 131L 6bon, NF 6gloq <br /> vice l a i t ` 2 <br /> V c C�iairmGn Dovc e1,1< 4 s} Po_a Rd s L.r�sor N� 6 £'8� <br /> ,gec/TreARSarcr alien cefa* coil K5T- Ord ,v£ S‘ 8.8% a <br /> c E O OfCUte Co-nyabe// a/4 N Oein e t /la st. niI RJE ‘8?at <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date ar <br /> Motor Vehicle Make ModelYear Body Type Vehicle ID Number I Date of Acquisition, <br /> if Newly Purchased <br />• <br /> SEE ATTACHED LIST <br /> Exempt Uses of Motor Vehicle: 'Are the motor vehicles used exclusively <br /> Agricultural/Horticultural ❑Religious 1g Charitable ❑Cemetery as indicated? <br /> ❑ <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES ❑NO <br /> T S 4-6—ti p x <br /> o r L cti c u e(a r n)e n fa/f I;S Ct e �.e.( If No,give percentage of exempt use: <br /> inet'u,dcrat s m,r.Ll pre tit'cle S <br /> ca- r-u rc e-S <br /> roe- s nl 10 1 a rn so_ of 77 <br /> Under penalties of law,I declare that 1 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 ' CA_y_b Arco. Dtaavr it-If- ate <br /> here Authorized SignalGG�``""' Title Date <br /> . <br /> FOR COUNTYTREASURER RECOMMENDATION ' <br /> PPROVAL RECEIVEDcOMME JTS: 4.455,0$' 77-cpenQ <br /> ❑DISAPPROVAL <br /> NOV• 1 6 2016 »-ad-/G' <br /> Signature of County Treasurer Date <br /> man rnt RUTy FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFlCE <br /> GRAND ISLAND.NEBRASKA <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL YJ <br /> -ff �i,r.�el acct,e nt— t /—/0 -// <br /> hori :.. 'nat Date <br /> •lebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d).and 60-3,185,and 603,169 <br /> 96-253-2008 Rev.8-2011 Supersedes 98-2532006 ROY.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />• <br /> I <br />