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DEC/18/201r/MON 03:29 PM Mid-Plains Center FAX No. 308-395-1060 P. 001 <br /> bit,.ti — I Application for Exemption FORM <br /> Nenrsab DeMmront of <br /> �j�''�/� `c from Motor Vehicle Taxes by Qualifying Nonprofit Organizations //y� �J <br /> Ili+Y GNiiJfra <br /> •Tit he sled with your county UeasWer. 46 <br /> anizzomm •Road Instructions on reverse side. <br /> Applicant's Name •• Type of Ownership <br /> Mid Plains Center for Behavioral Healthcare Services,Inc. _ ®Nalprom <br /> Skeet or Other Malting Address Courtly Corporation <br /> 615 N.Elm St., PO Box 1763 Hall ❑Ogler(SWIM: <br /> CM Stale Zip Code Stale Where Incorporated <br /> Grand Island, NE 68802 Nebraska , <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Tree Name,Address,Cl ty,State,Zip Code . <br /> PresldenVCE0 Cowie Edwards.816 N.Elm St.,Grand Island,NE 88801 <br /> _Vice President COO Abel Derr,615 N.Elm St,Grand Island,NE 88801 <br /> Finance Manager Brandi Nigro.815 N.Elm St,Grand Island,NE 88801 <br /> HR Director Amanda Groot,615 N.Elm St.,Grand Island,NE 68801 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,If necessary. <br />• Reglstration Date or <br /> Motor Whisk Make Model Year Body11ps Vehicle ID Number Date of Acquisition, <br /> If Newly Purchased <br /> Dodge 2001 Caravan 2B4GP44381 R213918 <br /> Dodge 2003 Caravan 2D4GP44353R298970 <br /> Pontiac 2005 Grand AM 1G2NE52EX5M146407 <br /> Ford • 2008 F250 1FT8X21528EE,22845 <br /> Dodge 20W Braun 2C7WDGe09GR313698 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used aramMely <br /> ❑AgdcdfuratMOrteutural ❑Educational ❑Rangioua 0 Charitable ❑Cemetery as Indicated? <br /> Ohre detatled deacdption d use,Including an espianalion amultiiple use dasaacatene exist ®YES ❑NO <br /> Vehicles are used to transport clients to and from other services such as our crisis If No,gwa percentage of exempt use: <br /> stabilization unit,youth services and employee transports. 1c <br /> 'Under penalties of law,I declare that I have examined aaa applkation and that II b,to the best of my Imowledge and bed,uue,complete,and Onset I <br /> also declare than am dilly authorized is alp We exemption appncaaon,and that tie arganlvtion owning me above-listed property doesnot disatrllnate <br /> in membership or employment based on recs.motor national origin. y� ^.�,, <br /> sign /W3t 4t' `IJ►i e 10 r Aidm <br /> here AutibriTed Signet'. Tale <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> L tisaz /424t.4_, A/...5; 5,. r7 7--...90.2....APROVAL —""il c $:∎ <br /> ❑DISAPPROVAL RECEIVED <br /> Ur, 1 8 2017 'agnat'e Chu eaaurer Data <br /> . FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> HALL COUNTY <br /> ErAPPROVAL TREASURERS Or40OS4ENT5: <br /> GRAND ISLAND,NEBRASKA • <br /> ❑DISAPPROVAL <br /> sigh / /—.?7g <br /> 1 A U. . .:, Signature Date <br /> Nebraska Departmra Of RMN1e Authorized by Nth,pax SW.§6 fl-o2(11(r)and(dl.and 504186,and 604.1889 <br /> as-M-2006 Re[Stil i Supermen 96.2 s4aoa Nee 6200. <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />