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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 Health Services, Inc. ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 615 North Elm Street P.O. Box 1763 Hall <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68802 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OP THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> CEO Come Edwards,P.O.Box 1763,Grand Island,NE 68802 <br /> 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 /> 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 /> Ford 2014 4D 1FADP3E20EL198745 06/05/2018 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgricuhuraVHortcultural ®Educational El Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ONO <br /> Provide non secure transports for youth in Nebraska at request of State Probation. <br /> 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 - Finance Manager 06/07/2018 <br /> here I Authorized Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> APPROVAL RECEIVED COMMENTS: /24—•---- �9`5. # "7 <br /> ❑DISAPPROVAL <br /> JUN 1 4 2018 -9 e>f6- �-' <br /> ,Signature of County Treasurer Date <br /> 1'REHrC ALL COUNTY T FO FOR COUP TY BOARD OF EQUALIZATION USE ONLY J <br /> GRAND ISLAND,NEBRASKA <br /> dg APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> ,Ihog na -2� mss' <br /> nr Signature <br /> Nebraska Department of Revenue • •ized• Neb.Rev.Stat.§§77.202{1)(c)and fa),and 60-3,185,and s03189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br /> • <br />