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File with Exemption Application FORM Your County for Tax Exemption on Real and Personal Property by Qualifying Organizations 451 Assessor Reed instructions on reverse side. I Failure to property complete or timely file this application will result in a denial of the exemption. Name of Organization County Name Tax Year Grand Island Area Habitat for Humanity Inc Hall 2017 Name of Owner f Properly State Where Incorporated Grand Island Area Habitat for Humanity Inc Nebraska Street or Other Mailing Address of Applicant Total Actual Value of Real and Personal Property Parcel ID Number 502 W. 2nd St. $20,000.00 400097249 City State Zip Code Contact Name Phone Number Grand Island NE 68801 Dana Jelinek 308-385-5510 Type of Ownership ❑Agricultural and Horticultural Society ❑Educational Organization ❑Religious Organization ®Charitable Organization ❑Cemetery Organization Name Title of Officers, Address,City,State,Zip Code Partn Directors,or Partners Julie Markvicka President 2140 N Park, Grand Island, NE 68803 Sara Seim V.P. 4044 Lambchop,Grand Island, NE 68803 Daniel Roth Treasurer 4153 Arizona Ave., Grand Island, NE 68803 Legal description of real property and general description of all depreciable tangible personal property,except licensed motor vehicles: Union Pacific Railway Co.'s 2nd, Blk 130, Lot 7 Property described above is used in the following exempt category(please mark the applicable boxes): ❑Agricultural and Horticultural Society ❑ Educational ❑ Religious ®Charitable ❑ Cemetery D9 Give a detailed description of the use of the property: c C V construction site for low-income housing Q 1016 Ail organizations,except for an Agricultural and Horticultural Society,must complete the following questions. Is all of the property used exclusively as described above? „41 YES ❑NO Is the property used for financial gain or profit to either the owner or owner or organization making exclusive use of the property? ❑YES ®NO Is a portion of the property used for the sale of alcoholic beverages? ❑YES 1:NO If Yes,state the number of hours per week Is the property owned or used by an organization which discriminates in membership or employment based on race,color, or national origin? r]YES f NO Under penalties of law,I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and complete.I declare that duly authorized to sign this exemption application. 9 12-1304‘, sin _ iz/ 30 here • E .J Authorized Signature The Date Retain a copy for your records. ,�/ For County Assessor's Recommendation • 0(I Approval 3_a`-`- COMMENTS: 1 1,' a©a. ❑ Approval of a Portion — i + v . V-- • i s -r / • �C _ z . \ • • • 'Denial ,. , ' r1 ntip r -s V l�g,,.�.&t—` 1 — VI— 11 ,�3- Q 1 Sigtatu i-C• my Assessor Date For County Boa • of Equalization Use Only I declare that to the best of my knowledge and belief,the determination made by the County Board of Equalization is correct pursuant to the laws of the State of Nebrr lkart �y]� Apprav€/f 4 rl�v(`a-4tZMENTS: ❑ Approval of a Portion � r-ax 7 eeni ./, e County Clerk:A legible copy of this form showing the final decision of the County Board of Equalization must be delivered electronically to the Nebraska Department of Revenue within seven days after the Board's decision. Nebraska Department of Revenue.Properly Assessment Division Authorized by Neb.Rev.Slat.1/2 77--202.01 and 77-202.04 96.135-1999 Rev,1.2014 Supersedes 96.135-1999 Rev.7-2012