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NIEST ^SI�A Application for Exemption <br /> ac FORM <br /> Good cre.Great Serdce from Motor Vehicle Taxes by Qualifying Nonprofit Organizations I FORM <br /> ,.,.,.„.,,,OF REVENUE •To be filed with your county treasurer. <br /> 457 <br /> 5 7 <br /> Name of Organization •Read Instructions on reverse side. <br /> Type of Ownership <br /> HEARTLAND HEALTH CENTER INC I Nonprofit Corporation <br /> Name of Owner of Property <br /> County (specify): <br /> County Name State Where Incorporated <br /> HALL NE <br /> Street or Other Mailing Address <br /> 3307 W CAPITAL AVE Contact Name y Phone Number <br /> City State Zip Code Email Address <br /> f e 1 Sok 7FZ- Y297 x S1tl <br /> GRAND ISLAND NE 68803047e `ohA <br /> Y cnG.OrS <br /> Identify Officers,Directors,or Partners of the Nonprofit Organization <br /> Title Name,Address,City,State,Zip Code <br /> 9 T♦ 4 ho . . Jail 7 <br /> MIMI <br /> Z QefY //?7 .T. 4..s X>! cm-) rss,,.1 Ale 6itet <br /> A • �' 6 —.. 4. .. . _ .. __ <br /> Description of the Motor Vehicles <br /> •:Attach an additional sheet,If necessary. <br /> Motor Vehicle Make Model Year Body Registration Date or <br /> (•� Y ype Vehicle ID Number Date of Acquisition, I <br /> 'JO�( 20/y w G if Newly Purchased <br /> ?CV ROGtGZER Zoo ssz 101111Lol% ) <br /> I <br /> Exempt Uses of Motor Vehicle: <br /> Are the motor vehicles used exclusivel <br /> ❑Agricultural and Horticultural Society Educational t( as indicated? <br /> y <br /> ❑ ❑Religious )(Charitable ❑C¢metery <br /> Give detailed description of use,including an explanation if multiple use classifications exist: III111”' <br /> A,t /f� )(IVES ❑NO <br /> S w ftWr4h Bu./;C7,,, Asi arah. ewe�on'ii oL o... /'•Awdr ./. ad AA. .•A...r .d 4-19-041-1 <br /> .S. arAr 4 (^On -'X.y An tent A ow yMy7,...r �L (.0 /y4.e n ei "r a� /440 If No,give percentage of exempt use: <br /> TA. .' .AJ% .R(..4 mrdk.d 1 de-id r rid 6Aiww4w/ AM. 'AG sc. it dA cMJ t4 pyc4 L <br /> 3s ol.•rs 1s its 4, a.r iodo. Zrr F; dud 74. cite previ.• ow awlkt id dttoet ra.l.,ro.r <br /> otdr ad pc°,c<•tt i6CF 1wpt 4 wall at G....) r2lr..J aA. dr.,'{ eaten) Y�"f O.% �ur <br /> d eM., eke:u. <br /> Under penalties of law,I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and complete. <br /> Iso declare the 1 am duly autho'zed to sign this exemption application. <br /> sign <br /> here Authorized Signature /^mi l•/ AA...e<�/' 1Z117-17-one <br /> Title Date <br /> For County Treasurer Recommendation <br /> �E <br /> ]Approval ents: L1! perIv Yes *1 E aA <br /> ❑Disapproval RECEIVED' <br /> DEC 1 3 2018 �i t& i U/lW lall13iig <br /> ignature of C my Treasurer �- _ ( Date <br /> For County E oard of Equalization Use Only <br /> J <br /> MALL COu21W <br /> TREASURERS OFFICE <br /> Approval GRAND ISLAND,NEBRASKA <br /> mments: <br /> ❑Disapproval <br /> V / <br /> ,P // <br /> Auth.rized Signatu : /L <br /> Date, <br /> Nebraska Department of Revenue <br /> 96-253-2006 Rev.7-201 a Supersedes 96-253.200R Rev.8-2011 Au horized by Neb.R .Stet§§1FP02(1)(cl and(d),and 60-3,185,and 663,169 <br /> Please retain a copy for your records. <br />