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207 <br /> ertn__ Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> MID-PLAINS CENTER FOR BEHAVIORAL HEALTHCARE SERVICES INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 615 N ELM ST HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68801 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City State,Zi Code <br /> C D C Orr iC Ethv40 5 WiNs#17 4n r S/4-id44,1 g'p-c j <br /> G 6 Pr�ScAcIekrr /2/�,7 Cc n /Tc/s,d//fE FG L4nce iMG/n �c,� &-b•, S G s/C-n Wu/ <br /> tO 6-3C5=/Off' _ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Bodyrype Vehicle ID Number Date of Acquisition, <br /> It Newly Purchased <br /> DODGE BRAUN 2016 SPT VAN 2C7WDGBG9GR313696 <br /> FORD 2008 F250 TRUCK 1:7x21528EE22845 <br /> FORE-- ----WOO rncn vny <br /> DODGE 2003 GRAND CARAVAN 2D4GP44353R298970 <br /> DODGE 2001 GRAND CARAVAN 2B46P44361R213918 <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,including an explanation if multiple use classifications exist: NYES ❑NO <br /> Vtl1J`cks gra- abed fa If rath5porf chat/ s k! 401 sore, otf/i <br /> l,ervICes Sk c.,44 5' The- 6r-15 I's 5L6,'A'74J, Unr {-Or^ If No,give percentage of exempt use: <br /> yeciHI cv}1515 trVJC4'S • 'I {leyure q/sa uSee/ oryypy/hf` <br /> p ployte4 '*b1 uS app 1y'es . <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 �., Sit/ (Pb_ae ► ( z'37/ <br /> here Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> A�. cycc_ <br /> '77_GQ� <br /> [�A1SPROVAL yLCCI • 1MENT9 /L� "a) <br /> ❑DISAPPROVAL <br /> NOV 3 0 2016 �� e'A-' /49 -8t- i <br /> /S'4 natu County Treasurer <br /> Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COONTY <br /> TREASURERS OFFICE <br /> �i�A <br /> ❑APPROVAL GRAND ISLAND,NE a(:UMMCMS <br /> ❑DISAPPROVAL <br /> Aillir <br /> Mr-zed i.riatur - Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 16-253-2006 Rey.8-2011 Supersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />