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JJN/20/2018/*ED 09:02 AM FAX No. P. 002 <br /> isken----e_.— Application for Exemption FORM <br /> Nebraska D.p.mn.nt of <br /> REVENREVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> UE G •TO he flied with your county treasurer. <br /> ,Read instructions on reverse tilde. <br /> APPIlconrs Name Type of Ownership <br /> Mosaic <br /> ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2846 Old Fair Road Hall Dome (specify): <br /> City Stale Zip Code Stale Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OETRE NONPROFIT ORGANIZATION <br /> Title N .Address,City,State,Lp Code <br /> See attached <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> -Attach an additional sheet,If necessary. <br /> Registration Date or <br /> Motor Vehicle Make ModelYeer NodyTyPe Vehicle IR Number Date of Acquisition, <br /> If Newly Purchased _ <br /> Toyota Sienna 2018 Minivan 5TOZZ30C2J5952306 <br /> Dodge Grand Caravan 2018 Wheelchair lift minivan 2C7WDGSO7JR307791 <br /> Exempt Uses of Motor Vehicle: i--I Are the mob vehicles used exclusively <br /> 0 AgrawltutaVHohia%urW ❑Educational �� ReagtcUs I„_I Charitable ❑Cemetery <br /> as indicated? <br /> Give detailed description of use,including an explanation if multiple use dewed/canons exist CI YES ONO <br /> Transport disabled individuals in Mosaic services MI r a-�+"h1^5 r r <br /> s L.p p 2'01%3 1 (W t r IC f °L'ppc•MI m-t.nv`fS) tJfY.g 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 Me best of my Miowledge and belel,true,complete,and correct.I <br /> also declare that I ant duly auaroneed to sign Mls exemption application,and That the organization owning the above-fisted property doss not discriminate <br /> In member or enlpbymtinl based on or,or neaonel origin. <br /> sign Administrative Assistant 6/14/18 <br /> here arbor sure Tae Data <br /> FORR COOUN`JTFWASURER RECOMMENDATION J <br /> [ RPPROVAL RECEI C&S: , �� 4' '1?q'o <br /> 0 DISAPPROVAL JUN 2 0 2018 <br /> 6-alt-ir. <br /> well rem lanry ,Sig ature of County Treasurer Cate <br /> I TREASURERBIVCGtl1EIY BOARD OF EQUALIZATION USE ONLY <br /> GRANS r5rAtvD,rvE9ftst8KA <br /> — <br /> APPROVAL COMMENTS: <br /> a. <br /> ❑DISAPPROVAL <br /> ..►�� 6`2--6 11 <br /> A • and SignTre Date <br /> Nebk <br /> rasa Department or Revenue — AatKKGad by Nee.Rev.Sat M n (1)(c)end(dl,end 593,115,end 00-0139 <br /> %4594909 Rai.94011 Supersedes 964584006 nev.54009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />