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N AG-4A- Application for Exemption FORM ,n Ufa creatservice from Motor Vehicle Taxes by Qualifying Nonprofit Organizations •To be tiled with your county treasurer. I 457 _•°•_•,.^•�•°=°r^ � •Read instructions on reverse side. 1 Name of Organization Type of Ownership UNITED VETERANS CLUB fknb•' 67a gird ©Nonprofit Corporation ❑Other(specify): - �w!!!! i Name of Owner of Property County Name State Where Incorporated HALL NE Street or Other Mailing Address Contact Name Phone Number 1914 W CAPITAL AVE Richard Simpson SOPS-384-99(1(1 City Stale Zip Code Email Address GRAND ISLAND NE 68803 simpsonrl@charter .net Identify Officers,Directors,or Partners of the Nonprofit Organization ■Title Name,Address,City,State,Zip Code Chairma u ' . ' . r - • : . ea Treasurer Verne Hit] 3228 W 18th St Grand Talanrt, N-E 68803 Director Richard Simpson 426 S Woodland I1rCrand To.lay.d , NE 688011 Description of the Motor Vehicles I •Attach an additional sheet,if necessary. j Registration Date or , Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, I it Newly Purchased Ford Econoline E3590 2014 Van 1FBSSBL3EDA71354 01/11/2017 1 1 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑Agricultural and Horticultural Society ❑Educational ❑Religious El Charitable E Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist: ErVES ❑NO Used to transport Honor Guard members to If No,give percentage of exempt use: perform military rites at funerals for deceased . veterans and parades honoring our country . 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. I also declare that I am duly a oriz sign this exemption application. Sign , �� here Authorized Signature Title Date 2�D4/lR i'" .T 1LIl.'+ reasuureer,Reecommendation C€v o titer r"` �,y�� AILS q17-?-� ��'ova! Comments: �J^ ❑Disapproval DEC 4 2018 AMINOHALL COUNTY ' l�L MIN act/Wit phhil12 TREASURFR,S OFFICE ignature of County Treasurer a e BRAND ISLAND,NE %SJ njv oard of Equalization Use Only ❑Approval Comments: // 1- ❑Disapproval / i Author,ed'Sign?'re Date/ Nebraska Oepanment of Revenue Authorized by Neb.Rev.Stal.§§77.202j1)(s)and Id),and 60-3,125.and 6,o--3.189 96-253-2006 Rev.7-2018 Supersedes 96-253-2006 Rev.11-2011 Please retain a copy for your records.