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aD/I <br /> +sue--�-- Application for Exemption FORM <br /> Nebneka Depercmem of <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicants Name Type of Ownership <br /> Grand Island Area Habitat for Humanity <br /> ®Nonprofit <br /> Street or Other Melling Address County Corporation <br /> 502 W SECOND ST PO BOX 1001 HALL Other(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 Name,Address,City,State,Zip Code <br /> PRESIDENT JULIE MARKVICKA,2140 N PARK,GRAND ISLAND,NE 68803 _ <br /> VP SARA SEIM,4044 LAMBCHOP,GRAND ISLAND,NE 68803 <br /> SECRETARY JENNIFER BERNTH, 104 LAKEVIEW CIRCLE,GRAND ISLAND NE 68803 <br /> TREASURER DANIEL ROTH,4153 ARIZONA AVE,GRAND ISLAND NE 68803 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> 'Attach an additional sheet,If necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> It Newly Purchased <br /> HYUNDAI GENESIS COUPE 2014 CPE 2.OT PREM A/ KMHHT6KD9EU 119156 12/31/16 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 9 AgriculturabHorticuttural 9 Educational ❑Religious ®Charitable 9 Cemetery as Indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: VES ❑NO <br /> THE CAR HAS BEEN DONATED TO BE RAFFLED OFF,WITH PROCEEDS BEING USED <br /> FOR HABITAT'S WORK IN THE AREA.THE VEHICLE MAY BE DRIVEN TO LOCATIONS If No,give percentage of exempt use: <br /> WHERE RAFFLE TICKETS WILL BE SOLD. <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 t 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 <br /> here ,Authorized Signature Title Da <br /> FOR COUNTY TREASURER RECOMMENDATION �/APPROVAL RECEIVE 'NIJ: �� �2 - X77 z).2, <br /> DISAPPROVAL <br /> � �g /6r1,7 <br /> •JAN 9 L��� It Signature u Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> riALL COUN 1 Y <br /> TREASURERS OFFICE <br /> APPROVAL GRAND ISLAND,NEELIVaretfuTS.. <br /> 9 DISAPPROVAL y <br /> ., • 6/7 <br /> r•rized Signa.r ;.to <br /> Nebraska Departmental Revenue Authorized by Neb.Rev.Stat.g§77-202(1)(c)and(d),and 80.3,1&5,and 603189 <br /> W253-2606 Rev.8-2011 Supersedes 96-253-2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />