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<br /> ....,_ Application for Exemption FORM
<br /> Nebraska Department of
<br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations
<br /> CIIIIMEnil •To be filed with your county treasurer. 457
<br /> •Read instructions on reverse side.
<br /> Applicants Name Type of Ownership
<br /> Heartland United Way, Inc
<br /> ®Nonprofit
<br /> Street or Other Meiina Address County Corporation
<br /> 1441 N Webb Rd Hail
<br /> ❑Other(specify):
<br /> City State Zip Code State Where Incorporated
<br /> Grand Island NE 68803 NE
<br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION
<br /> Title Name,Address,City,State,Zip Code
<br /> Presidenl/CEO Karen Rathke,3836 Meadowlark Cir,Grand Island,NE 68803
<br /> Board Chair Kelly Henry,68 Ponderosa,Grand Island,NE 68803
<br /> Board Vice Chair Mark Moravec,2804 Kingston Cir,Grand Island,NE 68803
<br /> Board Treasurer Wade Jarvi,309 Buffalo Grass,Grand Island,NE 68803 -
<br /> DESCRIPTION OFTHE MOTOR VEHICLES
<br /> •Attach an additional sheet,if necessary.
<br /> Registration Date or
<br /> Motor Vehicle Make Model Year !WY Type Vehide ID Number Date of Acquisition,
<br /> if Newly Purchased
<br /> Ford 2010 F150 1FTFXZICV6AKA9468
<br /> Haul mark 2014 Trailer 575PB1420EH264757
<br /> •
<br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively
<br /> ❑Agricultural/Horticultural ❑Educational ❑Religious ®Charitable ❑Cemetery as indicated?
<br /> Give detaied description of use,including an explanation it multiple use classifications exist ®YES ❑NO
<br /> Both pickup and trailer will be used for United Way programs,fundrisers and events.
<br /> Several programs involve hauling toys,food and hosehold furniture. They are used for If No,give percentage of exempt use:
<br /> hauling program items to community partners located in Hall,Hamilton, Howard and Merrick °6
<br /> counties. They are also used by staff to travel to United way functions that require hauling
<br /> event items locally,staewide and out of state.
<br /> Contact Karen or Carla 308-382-2675
<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 deda=that I am duly authorized to sign this exemption application,and that the organization owning the above-Ilsted property does not discriminate
<br /> In mem.- ip or emp. - t based on race,color,or national origin.
<br /> Sign i <,\� ll s / President/Chief Executive Officer 11-15-2017
<br /> here ,.Auth• -•`'Signature �' Tltie Date
<br /> FOR COUNTY TREASURER RECOMMENDATION
<br /> APPROVAL COMMCNT3: AK-art , /L- 4t1, S_S, 1C77- 90'.Z
<br /> ❑DISAPPROVAL RECEIVED
<br /> NOV 2 7 2017 � / IdQoeL 457-,aft/7
<br /> Signs ny Treasurer Date
<br /> I FOR COUNTY BOARD OF EQUALIZATION USE ONLY• HALL COUNTY
<br /> TREASURERS OFFICE
<br /> 1PPROVAL , GRAND ISLAND,NEBRASbOMM€4TS:
<br /> ❑DISAPPROVAL e q / Q�
<br /> O.d Signature Data
<br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet 077-202(1)(N
<br /> 96-253-2006 Rea 8-2011 supersedes 96.253-2006 Rev.5.2009 ()I)and(d).and 60.3,195,and 80.3,189
<br /> PLEASE RETAIN A COPY FOR YOUR RECORDS.
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