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Iseen----e. — Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> capanniman •Read instructions on reverse side. <br /> Applicants Name Type of Ownership <br /> Head Start Child and Family Development Program, Inc. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 123 N. Marian Road Hall <br /> D Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Hastings NE 68901 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Board President Lucinda Glen,123 N.Marian Road,Hastings,NE 68901 <br /> Executive Director Deb Ross,123 N.Marian Road,Hastings,NE 68901 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Chevrolet 2009 Colbalt 1G1AS58H797280633 June2018 <br /> • <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> El Agricultural/Horticultural ®Educational ❑Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: YES LINO <br /> Transportation of preschool children to and from the facility. Additional programmatic use (" <br /> If <br /> involving children, parents, and staff activities. 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 io 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 _-a.,2±) ,_..D,�n Executive Director 5/25/2018 <br /> here I Authorized Signature Title Date <br /> I FOR COUNTY TREASURER RECOMMENDATION <br /> ( 'PROVAL RECEIVED MENTc: S•S' ��-��� <br /> El DISAPPROVAL <br /> JUN ) 2O�p p. <br /> 4 O t � ] .�.`9 <br /> ( NAI t COI MTV <br /> Signature o Treasurer Date <br /> I FRTREASURNERRR ' Q NTV BOARD OF EQUALIZATION USE ONLY I <br /> ,yI APPROVAL COMMENTS: <br /> V� <br /> ❑DISAPPROVAL / <br /> ed Signature D <br /> Nebraska Department of Revenue Aufior,zed by Neb.Rev.Stab§§77-202(1)f c)and(d),and 60-3,185.and 60-3.189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5.2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />