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miken_.--t— Application for Exemption FORM <br /> Nebraska Department of <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 /> MID-PLAINS CENTER FOR BEHAVIORAL HEALTHCARE SERVICES INC j 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 OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> CS 0 e.a ri e CI - is T( 'BcC+,i,n dr,`✓e Cara 3- 610 64$0 <br /> (OO VT - ;r e, 'OK., 6 .-a&zd 1_ et, 4% 0 <br /> GPO nc-e,. - I iA,.(y 6 ► - .a..c Grass _cnt 'k-6 a' o/ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Dale of Acquisition, <br /> If Newly Purchased <br /> PONTIAC 2005 GRANDAM 1 G2NE52EX5M146407 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturauHorticultural ❑Educational ❑Religious 'Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,includit an planation a multiple use classifications exist: IR'4ES ❑NO <br /> 111:5Cqr 15 u U Nor frc,nS,roorIL, e/l/�ei5 fi0 oArd frown <br /> 5 r Cry$b 5A?L/,rz Q/44, yH / f No,give percentage of exempt use: <br /> ()Me yD�tfil1 Cr;S1 ter)/ r <br /> -_ _ (441 ci /s6 lie, ase I fa j-- ah 5,gird-e7l4y 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 popery does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign zueidii,��"" C c' 03//6 <br /> here Authorized Signature <br /> Title Dale <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> W6PROVAL RECEIVEDUMNtc,B: r 4/-4 °. <br /> ❑DISAPPROVAL <br /> N <br /> -i7 <br /> NOV 3 0 2016 / ��' <br /> Signature of CounryT Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE <br /> ❑APPROVAL GRAND ISLAND,NEBRA9S191MFAVS: <br /> ❑DISAPPROVAL <br /> O.Authorized Signature Dale <br /> Nebraska Department of Revenue lu lbodzed by Neb.Res Slat§§77-202(1)(c)and(d),and 60-3,185,and 603089 <br /> 942532006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />