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��� � � i � <br /> ��-� Application for Exemption � �� - FORM <br /> Nabraska Department nf <br /> REVENUE from Motor Veh�cle 7axes by Dualifying Nonprof�t�rganizations 457 <br /> •To be filed with your county treasurer. <br /> - •Read instructivns on reverse sidg. <br /> ApplicanYs Name Type ot Ownership <br /> Saint Francis Medical Center �Nonprofit <br /> Street or Other Mailing Address Counry Corporation <br /> 2620 W Faidley Ave PO Box 9804 Hall <br /> ❑Other(specify): <br /> Gity State Zip Code State Where Incorporated <br /> Grand Island NE 688�2 NEBR <br /> ID�NTIFY OFFICERS,171RECTORS,OR PAFiTNERS OF7HE NONPROFIT ORGANIZATIpN <br /> Title Name,Address,Ciry,State,Zip Code <br /> President Dan Mc�lligott;PO Box 9804;Grand Island,NE 68802 ���� �� <br /> Chairperson Mark Miller;617 W.3rd St.;Grand Island,NE 68801 _��� � �� <br /> Vice Chairperson 5usan Koenig;308 N.Locust,5uite 306;Grand Island,NE 68801 <br /> Ex-Officio RobeR Lanik;555 South 70th 5t.;Lincoln,N� 68510 � <br /> DESCRIP710N OFTHE MOTORVEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration bate or <br /> Motor Vehicle Make Model Year 6ody Type Vehicle I�Number Date of Acquisition, <br /> if Newly Purchased <br /> Chevrolet 2009 4�r Spt Util 3GNCA23B395632698 09-26-11 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles usod exclusively <br /> �Agricultural/Horticultural ❑Educational 0 Religious ❑Charitable ❑Cemetery as indicated7 <br /> Give detailed description oT use,including an explanation if multiple use classifications exist: �YES �NO <br /> Hospital use and Patient Transport. �� �� <br /> If N r f t use; <br /> % <br /> oc� z o zo�t <br /> 1-IA�..L CCrUN"['Y <br /> Under penalties of law,I deelare that I have examined this application and That it is,to the best of my knowledga a beliet,tr ' �, ��� K.S'A <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning fhe a�ov <br /> in membership or employmont based on race,color,or national origin. <br /> � <br /> J . � <br /> g � , , � � - <br /> s i n ��� .� -- l� � ��� f.��✓�.� 1�!N �_ ��// <br /> here ��zed Sig ture ��� Title � pate <br /> ���� � FOR COUNTYTREASURER RECOMMENDATION � ___ <br /> �.APPROVAL CQMMEN7S: Y �`�S ��/ ��GOt-, ��� <br /> ❑pISAPPROVAL <br /> ;�,�� /� ��_// <br /> Sig at e o °asurer Date <br /> � FOR COUNTY BOARD OF E�UALIZATIDN U5E ONLY m v�w� T�4��� <br /> �APPROVAL GOMMENTS: ..._ <br /> �QISAPPRdVAL •--•- <br /> �G ����� <br /> Authorized 5ignatur ��� Date <br /> NebrasKa Dvpartment ot Revenue Authorizod by Ne4.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,�BS,and 60-3.189 <br /> 96•253-2D06 Rev.8•2071 Supersedes 96-263-2D06 Rw.5��2009 <br /> PLEASE RE7AIN A CQPY FQRYOUR RECORDS. <br />