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zo WI <br /> Application for Exemption FORM <br /> a ��Nebraska Depamnem 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 /> Applicants Name Type of Ownership <br /> Head Start Child and Family Development Program, Inc. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 123 N. Marian Road Adams <br /> 0 <br /> City State Zip Code State Where Incorporated Other(specify): <br /> Hastings NE 68901 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Board President Lucinda Glen,Head Start Child and Family Development Program,Inc.Board President, <br /> 123 N.Marian Road,Hastigns,NE 68901 <br /> Executive Director Deb Ross,Head Start Child and Family Development Program,Inc. <br /> 123 N.Marian Road,Hastings,NE 68901 <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 /> See Attached List if Newly Purchased <br /> - <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agriculturaorticultural ®Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> lM <br /> Give detailed description of use,including an explanation is multiple use classifications exist: ®YES ❑NO <br /> Transportation of preschool children to and from the school facility.Additional programmatic <br /> use involving children,parents, and staff activities. If No,give percentage of exemp 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 employ ent based on race,color,or national origin. <br /> sign f Executive Director 11/14/2017 <br /> here 'Authorized Signature Tae Date <br /> I FOR COUNTY TREASURER RECOMMENDATION <br /> 9/, Sew <br /> 'r ?7 q peasZKMDPROVAL } 4tt' 9 Z — <br /> RECEIVE <br /> ❑DISAPPROVAL <br /> N 0 V 2 8 2017 1`�`�'-,ire ` /g'-�?�'-/7 <br /> • Signature o u Treasurer Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> 'TREASURERS OCE <br /> B APPROVAL GRAND ISLAND,NEFFI NTS <br /> ❑DISAPPROVAL . <br /> / 9—« <br /> iiirrized Sig . ure - Data <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§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 />