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Application for Exemption FORM Nebraska Depanmem 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 THIRD CITY CHRISTIAN CHURCH ®Nonprofit Street or Other Mailing Address County Corporation 4100 W 13TH ST HALL ❑Other(specify): City State Zip Code State Where Incorporated GRAND ISLAND NE 68803 NE IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code ELDERCHAIRMAN LARRY C GERDES 2510 PARKVIEW DR GRAND ISLAND NE 68801 TREAURER MARVIN DURYEE 8437 W WOOD RIVER RD WOOD RIVER NE 68883 SECRETARY GERRY RUTTMAN 2640 N NORTH RD GRAND ISLAND NE 68803 DESCRIPTION OF THE MOTOR VEHICLES •Attach an additional sheet,if necessary. Registration Date or MotorVehlcle Make Model Year Body Type Vehicle ID Number Date of Acquisition, N Newly Purchased FREIGHTLINER 2003 BUS 4UZAAWCT63CK65854 2-27-17 — Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑Agricultural/Horticultural ❑Educational ©Religious ❑Charitable ❑Cemetery as i d Sted? Give detailed description of use,Including an explanation If multiple use classifications exist 31 YES ❑NO THIS VEHICLE IS USED PRIMAIRLY FOR NON PROFIT CONNECT PROGRAM. IT MAY If No,give percentage of exempt use: BE USED FOR OTHER MINISTRIES OF THIRD CITY CHRISTIAN CHURCH. 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 90„, �%!Z DIRECTOR/CONNECT PROGR{J 3-22-17 here Aut d Signature Title Date FOR COUNTY TREASURER` , _R•ECOMMENDATION Et-APPROVAL RECEIVEY M MENTS: at42-"9 MMN'.95:45: ❑DISAPPROVAL MAR z 2 zo» C ° `a°'�' s- Q-9-'7 Signalu o C unty Treasurer Dale HALL COUN'IISOR COUNTY BOARD OF EQUALIZATION USE ONLY I KENSUHh kb 01-NICE GRAND ISLAND,NEBRASKA 911,APPROVAL COMMENTS: ❑DISAPPROVAL / %n Authorize.Signatur--� �� Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,165,and 60-3,1139 96-253-2006 Rea 62011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.