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201 % <br /> .--Z.. Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •TO be tiled with your county treasurer. 457 <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Third City Christian Church ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4100 West 13th St. Hall ❑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 /> Elder Chairman Larry C.Gerdes,2510 Parkview Dr.,Grand Island,NE 68801 <br /> Treasurer Marvin Duryee,8437 W.Woodriver Rd.,Wood River,NE 68883 <br /> Secretary Gerry Ruttman,2640 N.North Rd.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 Body Type Vehicle ID Number Date of Acquisition, <br /> it Newly Purchased <br /> Ford Econoline Wagon 15 Passenger 2003 • Van 1 F85531 S43HA47093 <br /> Ford Bus Chassis Cowls B800F 1990 . Bus 1 FDNJ65P6LVA12040 <br /> Freightliner Chassis FS65 2001 • Bus 4UZAAXBW11CH56883 <br /> Freightliner Chassis FS65 2003 ' Bus 4UZAAWCT83CK65855 <br /> Freightliner Chassis F565 2003 • Bus 4UZAAWCT63CK65854 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exckuively <br /> ❑AgriculturavHorticulturei ❑Educational ®Religious ❑Charitable ❑cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> These vehicles will be used primarily for nonprofit Connect program.They may be used for <br /> other ministries of Third City Christian Church If No,give percentage of exempt 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 or employment based on race,color,or national origin. <br /> sign c1~.t -44,9------ Erf„ht t4 t•s tcf 11/2.6/2e t <br /> here ,for Signature' Title Date <br /> FOR COUNTY TREASURER�RECOMMENDATION Al <br /> [IAPPROVAL ��.elpamcry i s £2 �y7 ,2"tA-' s:s, Atfl ,c t <br /> ❑DISAPPROVAL <br /> RECEIVED <br /> DEC zon 1 Signature Treasurer '°e2" ��.yam/7 <br /> . FOR COUNTY E OARD OF EQUALIZATION USE ONLY - 1 <br /> HALL COUNTY <br /> TREASURERS OFFICE <br /> V APPROVAL GRAND ISLAND,NE pwrc- . <br /> ❑DISAPPROVAL <br /> op / <br /> /— 9t IS <br /> dzed Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat§§71.202(1)(c)and(dl,and 603,186,and 80-3.189 <br /> 98.253.2006 Rev.8-2011 Supersedes 98-263-2006 Rev.52009 <br /> PLEASE RETAIN A COPY FORYOUR RECORDS. <br />