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� �oli <br /> `TQ BE FILEAWITH A►pplication for Exemption FORM <br /> from Motor Vehicle Taxes <br /> YOUR COl1NTY by Qualifying Nonprofit Organizations 457 <br /> TFiEA5L1RER •Read instructions on reverse side <br /> -- ---- <br /> Applicanfs Name County Type ot Pwnership <br /> GO�D SAMARI7"AN SOCIETY WOQD RIVER HAI.L __ �Nonprofit <br /> __.__.... <br /> Street or pther Mailing Address County Num6er Corporation . <br /> 1401 ]EAST ST 40 <br /> ___ _ [J Other(specify): <br /> ���y " State Zip Code Slate Where Incorporated <br />' WOOD RIVER NE 68$83 NE ---- <br /> _ _.. .. - ., � <br /> Identify Officers,Directors,or Partners <br /> _ __.. ___ _ _..- -- --- -- <br /> 7itle Name Addross,City,State,Zip Code <br /> _ -- _ _..... _—.. <br /> �'lease see-.attach�d. . <br /> � --_.. .,.... __ _... .._ <br /> LIST SPECIFIC�E5GRIPTION OFTHE MQ70R VEHICLES <br /> •Attach additional sheet if necessary <br /> _..., _ _._.__ _ . ._ _ —. . <br /> Registration Date or�ale <br /> Vehicle Make Modol Year eody Type Vehicic Identification Number ot Acquisitipn if fdewly <br /> Purchased <br /> __ ---- --- , . _ ._ _. _ __ — <br /> _ Dod�e_ _ ..... _.999 _ _. Carava.n Sport 2.Fs GP44SZOXI�2�'i7365 <br /> _.... _. <br /> GMC 1991 5ierra _ 1GTEK14K3�IE5165Q( .... <br /> --. . _ .. <br /> Ford __, .24Q�_,._ ar.. _ 2_EMI.�522/�7BA _.._ . -- <br /> Nature of Use o1 Motor Vehicle Are the motor vehicles used <br /> ❑Agricultural/Horticultural ❑Educational �Religious n Charitable ❑Gemetery <br /> exclusively as indicated7 <br /> Give deYailed description of use,including an explanation if multiple classificatinns exisC ._._....,.._ �YES n No <br /> Skillecl nursing facilit� owned and operated by ThP. _ IfNo, , <br /> _ _._ _ _ _.. ..._ _ <br /> Evan�elical Lutheran Good Samarit_an Society-Non Profit_.Status <br /> �� � - —r <br /> _ _. _. _ . ��� � �o�o <br /> � <br /> -- --- _ _. _ <br /> Under penalties of law,I declare that I have examined this application and,to the best ot my knowle e and beli � •��'C� <br /> camplete.I also declare that I am duly authorized to sign this exemption applicatian,and that the organization wning��� "r���A�� <br /> discriminate in membership or employment based on race,color,or national origin. <br /> • "µ� (' , <br /> sign ._� �_- � �� -�.�-.... ����,��,�.�.:��� _. _ �._._.` �` l� <br /> . -- _ _ <br /> here 'AutFiorized Sig�, u Title 6ate <br /> _ -- --- - --- ___ _ . <br /> FOR COUNTYTREASUR�R'S Ft�COMMENPATION <br /> _. -- -... -- <br /> --. _. <br /> _,.. ._ _ . .... _ _ -- -- <br /> i , <br /> �!/�APPROVAL COMMENTS. �'� , � �-� <br /> -��,� __�" _ . <br /> []DISAPPROVAL <br /> , �7 �G� <br /> " ;.�j� ���'� fcx — � "' <br /> _._._ -- — - -- <br /> Signature of Counry Treasurer CJate <br /> _ -- --- FOR COL1N7 —� <br /> Y BOARD OF EQUAUZATION USE ONLY <br /> � _.... _ _. _....,._ _.. _ _._.. . .. ._... _..-- <br /> �]APPRQVAL COMMENTS: ..._.. � <br /> ��ISAPPROVAL � _.. �` � � --� ---- ----., f � � __. <br /> � ��, f <br /> . <br /> , � _- �..=-: <br /> -- .-- _ <br /> Authorized Signature � Date <br /> _,. __.... . - <br /> NC6raska�epartmenl of Ravenue Authorized by Neb.Rev.Stat.§77-202(7�(c)(d),§GO-3,185§60�3,189 <br /> 96-253-200G Rev.5-2009 SuperSedes 96-253-200G Rev.11•2008 <br /> PL.EASE MAKE A COPI'FOR YOUR RECpRDS <br />