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Application for Exemption i <br /> Nebraska Department of FORS, <br /> REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treat:wee <br /> mmainrace •Read instructions on reverse aide. <br /> Applicant's Nas <br /> a .-_.._ Type of Ownership—.._._. <br /> SENIOR CITIZENS INDUSTRIES INC Nonprofit <br /> Street or Other Mailing Address 5 County Corporation <br /> 304E THIRD ST HALL <br /> City ❑Other tsperay): <br /> Y State Zip fivse I State Where Incorporated <br /> GRAND ISLAND NE 68801 i NE __________ <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tins I Name,Address.Ciy,States Zrp Cods <br /> • L5/... ... --._ —__ _.—___._ <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> *Attach an additional sheet,if necessary. <br /> I I I Registration Data or <br /> Motor Vehicle Marx I Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> 1---- _ _. I _ y if NowixPUrehasad._ <br /> I <br /> i <br /> i <br /> Exempt uses of Motor Vehicle: ---_ _—_._ I Are the motor ve notes used azdusivatiy <br /> [1 AgrkzdvretMMorticultural C Education! ❑Re;lgzws WCharitat%e 0 Cemetery ins indicated? <br /> I <br /> Give detailed description of(use,including an explanation if multiple use classitcaawts exist: t / I I &S V NO <br /> {mss 1)eh cie 16 ineC - "its d kt OCT 1'&A'+e Centered i /� <br /> Ili No,give percentage of exempt use: <br /> rn C605 'ro S.e/ltiarS ih a (Attn. Ldp arc <br /> i <br /> deemed as home bauic. seruars, <br /> I <br /> 1 <br /> Under penalties of taw,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 sin duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> In membership or employment based on race,color,or national origin. <br /> sign ll <br /> Ai <br /> here Authorized Signature / Date <br /> L n u FOR COUNTYTREAASS�UREER,RE�COOMMENDATION <br /> [y APPROVAL C>LIVia�OFAMt7RTS: f „"'1`�_ !tan- /�I,.l.•� - 7-7-.7.02_, <br /> 0 DISAPPROWAL —�—_-- •/� <br /> DEC - 5 2017 d >a--pe->7 <br /> Signs , reasurer <br /> Data <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY _ <br /> TREASURERS OFFICE <br /> APPROVAL' GRAND ISLAND,NESRA$f „�,ig�TS: <br /> 0 DISAPPROVAL <br /> Signsbrm Date <br /> Net-ens Daparanent or Revenue Authorized by Nee Rev.SW.§¢?7-202(1f(ra:nd(di,end en 4,185,and 804,taq <br /> 05-253-2006 Rex 8-2011 Suserse es 28.253.21%16 Rev 5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />