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2011
<br /> To�E.�,���m�:,�M Application for Exemption �oRM
<br /> ,�.XAJJ.Fi COUNTY from Motor Vehicle Taxes
<br /> TREA5URER by Qualifying Nanprofit Qrganizations 4C'7
<br /> •Read instructions on reverse side �
<br /> ApplicanYs Name f ^ � � � � County Type of Ownership
<br /> SAINT FRANCIS MEDIGAL CENTER HALL Q Nonprotit
<br /> Street or Other Mailing Address County Number Corporation
<br /> 2620 W FAI[71��Y AVE PO BOX 9804 �F� � 40 �piher(specify):
<br /> Gity State �Zip Gode 5tate Where Incorporated
<br /> GRANQ ISLAND NE 68802 NE
<br /> Identify Officers,Directors,vr Partners --�Y4 �.f_
<br /> ........._.._._ __....__ ____._.,�..�_....__
<br /> 7'itle Name,Address,Gity,State,Zip Code
<br /> ... ....,.__— _._..._. _.,,.,..._._._..._
<br /> PRFSIDENT �an Mc�lligott; Sainl Francis Medical Cenler; PO Box 9804; Grand Island,NE 68802
<br /> GHAIRPERSON Mark Miller, Eakes dffce Plus; 617 W.3rd Street; Grand Island, NE 68801 �� ---- °--_._._�
<br /> �.—_. ..--- �...... _..__...
<br /> VIGE CWAIRPERSON Susan Koenig; May,Burns, Koenig&Janulewicz; 308 N.Locust,Suite 306; Grand Island,NE 68801
<br /> —.....__—— -------..,..__---- ----_.......__ _,...
<br /> F_X-OFFIGIO Robert Lanik; Saint Elizab�th Reqional Medical Center, 555 South 70th 5treet; Lincoln,NE 6851p �
<br /> TRCASUR .....__...___.�_ _..�... _..�. __._..__.... ...— _,...,.......
<br /> CR Daniel Naranjo; All Faiths Funeral Home; 2929 S.Locust Street; Grand Island,NE 68801
<br /> ____....__..�..r,...__� .�.,...._____— �._..�__..--- -_....._..--
<br /> L.IS7 SPECIFIC 17�SCRIPTION QFTHE MOTOR VEHICLES
<br /> •Attach additional sheet if necessary
<br /> �_____.......,,.�.�.___.�._.�....... _�._,,...�.�....._..._.�_ _ ."''"`_ Registration Da4e or Uate
<br /> Vehicle Make Model Year 8ody Type Vehicle Identification Number of Acquisition it Newly
<br /> —_.._...__._w W,,.,. ._.�..__.
<br /> Purchased
<br /> 5CC A77ACHED LIST _____.._� .. ,_.�._,.._
<br /> Nature oi Use of Motar Vehicle �� y � Are the mntor vehicles used
<br /> �Agricultural/Horticultural �Educational �Religious �Charitable �C�melery exclusively as indicated?
<br /> Give detailed description of use,including an explanation il multiple classifications exist: �Y�S �NO
<br /> Hospital Use: Transport of Patients y
<br /> 7ransport of Maintenance �quipment between two buildings If No,���e �� a� r•a .r� :�,
<br /> „��
<br /> � 1�'OV ,� 3 �4��
<br /> � Under penalties of law,I declare that I have examined this application and,to the best oi my knowledg and belief,I�Rs�p� MTY�
<br /> complete.I also declare that I am duly authorized to sign this exemplion application,and that the organization o '� ppytj!� ����IC�
<br /> disoriminate in membership or employment pased on race,color,or national origin. �gRASKp
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<br /> Slgfl � f
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<br /> onzed Si nature ���� �� Title � � J
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<br /> _______ _ �.. .___.__ �__..._._
<br /> FOR COUN7YTREASUHER'S RECOMMENDATION
<br /> ___�._. __.__T..._._._ ..__.__ ____...�.._---�
<br /> ��t APPROVAL COMMENTS: r�j-� �/r�G-T� _ �
<br /> �PISAPPROVAL .... _ _..--- --.,__
<br /> ��� ,.
<br /> , �� � �; l� /e _��lG�
<br /> __....__ .._.— _._�
<br /> Signature of County TYeasurer Date
<br /> �----�..,... r...m_.. _...__ _.m._..----
<br /> � FOR GOUNTY BdARP O�EQUALIZATION USE ONLY �
<br /> (�APPROVAL COMMEN7S: .... _,. _-- ..._,_ _,,.
<br /> � .
<br /> �DISAPPRbVAL ..T._._ % ____ �/ ' . . ____
<br /> � � I/t,�� ---
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<br /> Authprized Signature — W Date
<br /> Nebraska�epartment ol Hevenue �� �W � Authofiied by Ne6.Rev.Stat.§77-p02(1)(C)(d),§60-3,185§60•3,189
<br /> 9E253-2006 Rev.5-2009 Suporsodcs 96-253-2006 Rev.11-20U8
<br /> PLEASE MAKE A COPY FOR YOUR RECORDS
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