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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 /> Third City Christian Church ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4100 West 13th St. Hall ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address.City,State,Zip Code <br /> Elder Chairman Larry C.Gerdes,2510 Parkview Dr.,Grand Island,NE 68801 <br /> Treasurer Marvin Duryee,8437 W.Woodriver Rd.,Wood River,NE 68883 <br /> Secretary Gerry Ruttman,2640 N.North Rd.Grand Island,NE 68803 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYear Body Type Vehicle ID Number Date of Acquisition, <br /> N Newly Purchased <br /> 2005 International-IC 2005 Bus 4DRBUAFP45B979438 11/21/2017 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exckuivey <br /> ❑Agriculturakliorticulturei ❑Educational ti.4. Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> This vehicle will be used primarily for nonprofit Connect program. It may be used for other <br /> ministries of Third City Christian Church If No,give percentage of exempt use: <br /> as <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 -- 0" / Sy, //oe ''2 7;y4cirr e <br /> here Aut orized Signature Title Date <br /> FOR COUNTY TREAS�UREER,RECOMMENDATION <br /> �41:0,5-.Z.- I <br /> 1 [APPROVAL RECEIVE QOMMENTS: 0���2innPa -' r`� 77 <br /> ❑DISAPPROVAL <br /> 7 2017 <br /> DEC b /a- 7-47 <br /> 1 taaU COUat^r Signat heasurer Date <br /> J TREASURERS OFFICE COUN-Y BOARD OF EQUALIZATION USE ONLY <br /> rr,,{{{{ar —et-AND-LA/a Milt DRA�,IM <br /> $APPR$APPROVAL COMMENTS: / <br /> OVAL <br /> DISAPPROVAL ��p�A�=<�,�f/G� <br /> p J iD-J7 <br /> Authorized atu Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat§§77-2020)(0)and(d).and 60.3,185.and 603,189 <br /> 96-253-2006 Rey,8-2011 Supersedes 963532006 Re+.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> I <br />