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2alg <br /> _ Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •T0 be filed with your county treasurer. <br /> •Read Instructions on reverse side. <br /> Applicants 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( ) <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE 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 OF THE 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 Newly Purchased <br /> If N <br /> international-IC 2005 Bus 4DRBUAFP45B979438 11/21/17 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultura4HortkadNral ❑Educational ®ReIgious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of Ice,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 4 � G><eL tit r�'� 5 ✓ it 7 <br /> here Autho Ized Signatu Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> PPROVAL WS: e'"jilt 'fie � S,S, 4-77,9.,).2, <br /> RECEIVED <br /> ❑DISAPPR AL -,.„' <br /> DEC 7 2017 Qefgg� ✓47-4,-/7 <br /> Signature of County Treasurer Date <br /> FOR CO TY BOARD OF EQUALIZATION USE ONLY • J <br /> HALL TREASURERS OFFICE <br /> IdAPPROVA ti 0ISLAND NEBRASK.QOM ENTS: <br /> ❑DISAPPROVAL )-7$2( <br /> / <br /> zed Signature - Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat§§77-202(1)(c)and(d),and 60-3,185,and 603,189 <br /> 96253-2006 Rev.82011 Supersedes 96253.2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />