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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 /> Applicant's Name Type of Ownership <br /> Diocese of Grand Island ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2708 Old Fair Rd Hall 0 Other(speedy): <br /> City Stale Zip Code State where Incorporated <br /> Grand Island NE 68803 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Bishop/President Most Rev Joseph Hanefeldt,2708 Old Fair Rd,Grand Island NE 68803 <br /> V-President Rev Charles Torpey,2635 Brenne Land,Grand Island NE 68803 <br /> Sec/Treasurer Rev.Michael McDermott,4110 Cannon Rd,Grand Island NE 68803 <br /> DESCRIPTION OF THE 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 /> if Newly Purchased <br /> Pontiac 2008 4 Door Sed 1G2ZF57B784151908 5/27/2017 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturalMorticultural ❑Educational © Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: I YES ❑NO <br /> This vehicle is used solely for religious/charitable purposes <br /> If No,give percentage of exempt use: <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 /> sign y id- Title —P2�zsropit/7' �3^ far <br /> here ?*thorized Si nature Title Data <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> _ .!, NTS: 1//an-A2 - 95-457 7 9-a7 42_ <br /> Q'�PROVA RECEIVED <br /> ❑DISAPPR•. AL .•,+ <br /> JUN5 2017 ►Signature unty Treasurer Date <br /> FOR CO NTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> TREASURERS OFFICE GRANI LAND EBRASWGOM ENTS: <br /> ❑DISAPPROVAL <br /> pIF <br /> si 7 <br /> Authori t•Signature V Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.%77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />