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ao 7 <br /> ar,„- 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 />• <br /> licant%Name <br /> Type of Ownership <br /> SENIOR CITZENS INDUSTRIES INC ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 304 E THIRD ST HALL ❑O)er(spedy): <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,Zip Code <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Motor Vehicle Make Modal Year I Body Type Registration Date or <br /> Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> DODGE 2010 GRAND CARAVAN • 2D4RN5DX5AR192152 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ❑Religious [9Charitaue ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: _ P Ni'ES ❑NO <br /> -41t5 Van 15 ,u,/s eck -ko deli Te r 1�or1e `�e�ipyered <br /> '{✓ San t V1 S •/,` . . ..7.5. <br /> If No,give percentage of exempt use: <br /> Me.0 s a disabi�d 1nC di <br /> Who art I l hpv1 e ba ttvi • Ir <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 /> • <br /> sign �C '!c4.s. _,t: La - iI �� illaif 6 <br /> here I'Alithari dSignature Title Date <br /> I FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVEDMENTS L _ fie--4---- A4'45: X77 `-,7c <br /> ❑DISAPPROVAL <br /> NOV 2 9 2016 �> _,()jy�r ... / ;/7 <br /> •{Sig_gnatuure ofof�County Treasurer Date <br /> HALLCa Qh16 AUNTY BOARD OF EQUALIZATION USE ONLY • J <br /> In P.E EPS JC" <br /> GRAND ISLAND,NEBRASKA , <br /> p APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> thorized ignat! Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.45 77-202(1)(c)and(d),and 60-3,195,and 603,189 <br /> 95253'2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />