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ae0/l �^--L Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •Read instructions on reverse side. Applicant's Name Type of Ownership Grand Island Area Habitat for Humanity j Nonprofit Street or Other Mailing Address County Corporation 502 W SECOND ST PO BOX 1001 HALL ❑Other(specify): City State Zip Code State Where Incorporated GRAND ISLAND NE 68802 NE IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code PRESIDENT JULIE MARKVICKA,2140 N PARK,GRAND ISLAND, NE 68803 VP SARA SEIM,4044 LAMBCHOP,GRAND ISLAND,NE 68803 SECRETARY JENNIFER BERNTH,104 LAKEVIEW CIRCLE,GRAND ISLAND NE 68803 TREASURER DANIEL ROTH,4153 ARIZONA AVE,GRAND ISLAND NE 68803 DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,if necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number j Date of Acquisition, if Newly Purchased HYUNDAI GENESIS COUPE 2014 CPE 2.OT PREM N KMHHT6KD9EU119156 12/31/16 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑Agricultural/Horticultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist: 01 YES ❑NO THE CAR HAS BEEN DONATED TO BE RAFFLED OFF, WITH PROCEEDS BEING USED FOR HABITAT'S WORK IN THE AREA. THE VEHICLE MAY BE DRIVEN TO LOCATIONS If No,give percentage of exempt use: WHERE RAFFLE TICKETS WILL BE SOLD. 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 also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. sign ii, L here I Authorized Signature / Title Da FOR COUNTY TREASURER RECOMMENDATION Ii;}"FCPPROVA■ RECEIVED n''•"AMTS. !rte!' tiar DISAPPRC VAL /el JAN 9 2017 /Signat�y Treasurer Date FOR COL NTY BOARD OF EQUALIZATION USE ONLY HALL COUNTY EASURER ❑APPROVA, GRAND ISLANDS EBFRASIOAOMMENTS: ❑DISAPPROVAL — .41c/ ff/ uthorired Signatur." e Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§¢77-202(1)(c)end Id).and 60.3,185,and 60-3.189 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.