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een-----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 /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Mid-Plains Center for Behavioral Healthcare Services, Inc. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> P.O. Box 1763 Hall ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68802 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City.State,Zip Code <br /> CEO Come Edwards,P.O.Box 1763,Grand Island, NE 68802 <br /> i COO Mel Derr,P.O. Box 1763,Grand Island,NE 68802 <br /> Finance Manager Brandi Nigro, P.O.Box 1763,Grand Island,NE 68802 <br />• <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 Acquisition, <br /> if Newly Purchased <br /> Chevrolet 2012 40HB _ 1G 1JA6SH3C4174321 05/23/2018 <br /> Exempt Uses of Motor Vehicle: o Are the motor vehicles used exclusively <br /> ❑AgriculturayHorticultural ®Educational ❑Religious Ig,Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 1D YES ❑NO <br /> Employees use the vehicle to provide a variety of home-based Behavioral Health Services. No,give percentage of exempt use: <br /> If Employees will also use the vehicle to drive to and from training activities. <br />• <br /> r <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 Finance Manager 05/31/2018 <br /> here ,Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION A-'q 'ar�.PPROVAL RECEIVE[JMMEN 'S: . i-a /-- N 7� <Z• <br /> ❑DISAPPROVAL <br /> JUN d 2018 C � a° � -s=..",e' <br /> It Signature of unty Treasurer Date <br /> HALL COUNNT F1POUNT.BOARD OF EQUALIZATION USE ONLY <br /> _ GRAND ISLAND NEBRASKA <br /> APPROVAL COMMENTS: <br /> TTT . <br /> ❑DISAPPROVAL Q <br /> '. / 7 �a;/��U <br /> ,. ,• Autho -•Signature ae <br /> • <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(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 />