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• File with Exemption Application FORM Your County for Tax Exemption on Real and Personal Property by Qualifying Organizations J1 Assessor Read instructions on reverse side. 451 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 0 11 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 502W2ndSt. $ a0r00D 11TOE I4, Zj Z 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 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: evetpis Aoki i31(< L01" 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 ® Charitable ❑ Cemetery HALL CQLJNil ASSESSOR Give a detailed description of the use of the property: GRANS I53�PJD, N�RRASKP. Property has been acquired as a site for Habitat for Humanity housing. ?ref worlc_ 1n.us Ie2JLtfl 1-0L,14,4in`\ puti- canLtn . ConShur tOvn enc Councl c -i O en 13 Se_A- FO r 1.1 , IPI o ns Vl&Are_ e-tv-t All organizations,except for an Agricultural and Horticultural Society,must complete the following questions. • • Is all of the properly used exclusively as described above? 14;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? DYES IN NO Is a portion of the property used for the sale of alcoholic beverages? DYES ®NO H Yes,state the nth,Aler 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? t ❑YES FL NO Under penal--s 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 a •clere that I am•. au on t•to sign this exem•ion application. Sign A - i-al ✓Ltoh_ales. Executive Director bli (/ 7 here Authorized Signature Title Date Retain a copy for your records. For County Assessor's Recommendation Approval COMMENTS: 1-1` ❑ Approval of a Portion P. 0 Denial Signature (gun Assessor Date For County Board 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 Nebraska. *Approved COMMENTS: lIIJJJ❑��l��,Approval of a Portion A ' ❑ Denied // 0240/7 Signature o County Board tuber 99ti4to 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.Stet.077-20101 and 77-20214 96-1352999 Rev.1-2014 Supersedes 96-1351/099 Rev.72012