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DEC/18/2017/MON 03:29 PM Mid-Plains Center FAX No, 308-395-1060 P, 002 mien---e.- Application for Exemption FOAM Neereela Wynmem or REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be tried with'your county treasurer. •Reed Instructions on reverse side. Applicant's Name Type of Ownership Mid Plains Center for Behavioral Healthcare Services, Inc. ®Nonpren Street or Other Malting Address County Corporation 615 N. Elm St, PO Box 1763 Hall [}par(specify)! City State Zip Code State Where Incorporated Grand Island, NE 68802 Nebraska IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Tine _Name,Address,Clty,State,Zip Code President/CEO Comie Edwards,615 N.Elm St.,Grand Island,NE 66601 Vice President/COO Ariel Den.615 N.Elm SL.Grand Island,NE 68601 Finance Manager Brandt Nigro,815 N.an St.Grand Island.NE 88801 HR Director Amanda Croat.615 N.Elm St.,Grand Island,NE 68801 DESCRIPTION OF THE MOTORVEHICLES •Attach air additional sheet,H necessary. • Regletration Data ar Motor Vehicle Make Model Year Body Type Vehicle ID Number Dale of Aoqulaalan, it Newly Purchased 'MFG 2007 Trailer 4YMUL8177M065786 Exempt Wee of Motor vehicle: Are the motor vehicles wed exclusively - ❑AgdcuMralMorhcufudi ❑Educational ❑Religious 121 Charitable ❑Cemetery as vidleeted7 I Give detailed desoiptcn of use,including an explanation If multiple usa eleasttcaaons Sat: Nves ❑NO This trailer is used to haul goods to the company,as well as haul items from the company, IfNo.gam pa:enlace of cornet we: x Under penalties of law,I declare ball have examined this aep6cartmt and that it is 10 the test Ot my lomeedge and ballet,true,mnpleie,and correct.I also declare that I am duly authorized to sign this exemption application.and that the organization owning the above-Mod property does not disaintate h ma•Brehm or employment based on race,odor.or national origin. sign 1 1 • 0 & a ' . f AIL:k v- 12 i here ■Audi. Signature Tele Dale ,,�, FOR COUNTY TREAS�URREER Ry,E,COMMENDATION Cy�/wPROVAL RECEfV�"'ENTS.. 'r 00—"- �N A S,S 4r7.7I4daa ❑DISAPPROVAL DEC 1 8 2017 <° di 22" /a c9d'-/7 fregneture of Coon Treasurer Data FOR COUNTY BOARD OF EQUALIZATION USE ONLY - 1 RAILC6UNTV TREASURERS OFFICE In APPROVAL GRANO ISLAND,NattilMINTS.r, I v ❑DISAPPROVAL • i ,. ed Signature Oats Nebraska OtparenemOl Rasnre Authorized by Neb.Res SIN.9a 77-20r(MC)W1*NA tiro 60-1.105,sail 604,109 90455.2000 An 5-2011 Supersedes e5. &aooe few.24009 PLEASE RETAIN A COPY FOR YOUR RECORDS.