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im-n--Z- Application for Exemption FORM <br /> Nebraska Dapammx o n of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 57*To be tiled with your county treasurer. <br /> MIMMIZ__-_--_._ •Read Instructions on reveres alde. <br /> Appfk¢nVs Name Type of Ownership <br /> HALL COUNTY C/O SENIOR CITIZENS INDUSTRIES INC I �i Nonprofit <br /> Street or Other Mailing Address I County I Corporation <br /> 304E THIRD ST I HALL ` <br /> I D Otter fsesodY): <br /> City State Lp Code I Slate Where incorporated <br /> GRAND ISLAND NE 68801 1 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tide Name,Address.City;State,Top Coda <br /> 1 <br /> i <br />• <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> *Attach an additional sheet,If necessary. <br /> ' i 1 Registration Date or <br /> Motor Vehicle Make I ModelYear I Body Type Vehicle ID Number Date of <br /> ___... Acquisition <br /> I I Newct , <br /> j <br /> ._____------__ <br /> i <br /> i - — I - 1 <br /> Exempt Uses of Motor Vehicle: 1 Are the motor vehicles used exclusively <br /> ❑AgrkuHUralMoniaria;ral 0 Educational 0 Ramous ET Charitable Pi Cemetery I as indicated? <br /> Give detailed description ol use,including an explanation if multiple use classifications exist: i AYES n NO <br /> �j 1 FFF--'TTT <br /> \\ <br /> TAM WU—' t`erg QQti' )L ��L-t s.\ 'C, i li No,give percentage of exempt use: <br /> v \` ' i <br />• <br />• <br /> • <br /> Under penalties of law,I declare that I have exarrrned this application and that it C.to the best of my knowledge and belief,true.complete,and correct.I <br /> also declare that I am duly authorized to age this exemption application,and that the organization owning the above-fisted prgntrtyy does not discriminate <br /> In membership or employment based on race,color,or national origin. <br /> sign � �? v _ ,.tom; , S2ae, //-.�'o-/ 7 <br />• <br /> here 'Wired Sigtatare True Date <br /> _—_--- — FOR GOWN TREASURER RECOMMENDATION ��// • —_—J <br /> . <br /> APPROVAL PaS, pre �� IG(IMMtN "' — - / ry ��' 7�4o� <br /> 0 DIS lfkcltl+ 11VV.. 1lLi//lI 2017------- ---------------- <br /> DEC ATION USE ONLY <br /> L FOR C <br /> .._..__.-.-... — —OUNT — -- — — <br /> • ASRERSO <br /> TREASURERS OFFICE <br /> r-, .PPROVAL GRAND ISLAND,NEBRAWM g: <br /> N. <br /> EJ DISAPPROVAL <br /> 11111 , <br /> Dale-- <br /> Nebraska-253- 00 Re'. 8-2 of Ramose Amerind by Nei Rix.Slat.§§TJ-2D2(1xc;and(tlt,and¢04,185,and BbS,fE9 <br /> a¢25.Y278 Rev.&Litf 8slraraauw 96-a18.2006 Rev 5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />