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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. Failure to properly 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 c Q I 1 Name of Owner of Property 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 502W 2nd St. $ r;0r00() 4-001Z031t4- 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 [2j Charitable Organization ❑Cemetery Organization Name Title of Officers, Address,City,State,Zip Code Directors,or Partners Brian Schultz President 812 W. 15th,Grand Island. NE 68801 Matt Bennett VP 2524 W. Phoenix, 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: Svons Add . 31K Lc+ 3 RECEIVED MAY 3 1 2017 Property described above is used in the following exempt category(please mark the applicable boxes): ❑Agricultural and Horticultural Society ❑ Educational ❑ Religious ii Charitable ❑ Cemetery HALL COUNTY ASSESSOR GRAND ISLAND, NEBRASKA Give a detailed description of the use of the property: Property has been acquired as a site for Habitat for Humanity housing. Con s}rt,tc#-coin is June 17- Sap+. 13 f Ci_ns 6 ld-.) ,p-1- -Cov Per inn- - - All organizations,except for an Agricultural and Horticultural Society,must complete the following questions. Is all of the property used exclusively as described above? /X$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 k•NO Is a portion of the property used for the sale of alcoholic beverages? ❑YES F.r. 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? ❑YES 1t 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..II�f,leo declare that 1 my a thorized to sign this exemption application. Sign ' J Executive Director 4_2//41___ here Authorized Signature Title Date Retain a copy for your records. For County Assessor's Recommendation Approval COMMENTS: • ❑ Approval of a Portion ❑ Denial I . . / % 1 Signature.�.0 ty Assessorr 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 r� laws of the Stale of Nebraska. YV Approved COMMENTS: �❑\Approval of a Portion ❑ Denied Sri��._ �,SL_-- . 04...2././.±=70/7 ignature of County Beard ember to 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,Property Assessment Division Authorized by Neb.Rev Slat.§§77-202.01 and 11202 04 96.135.1999 Rev.1-2014 Supersedes 96.135-1999 Rev,7-2012 •