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d._----� . . '� J � � <br /> ,�.�- Applica�NOn for Exemption FORM <br /> Ne6raska Department of <br /> REVENUE from Motor VehicleTaxes by Dualifying Nonprofit Organizations 457 <br /> •To be flled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> GOOD SAMARITAN SOCIETY WOOD RIV�R �rvonpro�it <br /> Street or Other Mailing nddress County Corporation <br /> 1401 EAST ST HALI. <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> WOOD RIV�R NE 68883 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS QFTHE NONPROFIT pRGANI�Al"ION <br /> Title Name,Address,City,State,Zip Code <br /> please see attached . <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle Ip Number Date of Acquisition, <br /> it Newly Pu�cria5ed <br /> e 1999 Caravan S ort 2B4GP44ROXR207365 <br /> GMC 1991 Sierra l.GTEKI4KXME516506 <br /> Ford z007 Freestar 2F'MZA52247BA02760 <br /> Exempt Uses of Motvr Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational [��Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanetion if multiple use classifications exist: �YES �NO <br /> f No,give p e � � <br /> Skil.J�ed nursin.g .facility owned and operated by The Evangelical <br /> Lutheran Good Samaritan Socie�y-Non Profit Status. <br /> NOV 1 7 Z011 <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best pf my knowledge and belie,true,complete,�Ab�kr[�C1t.INTY <br /> also declare that I am duty authorized to sign this exemption application,and that the organization owning the above-listed roperty doe�dis�r�c�O�}_�r� <br /> in membership or employment based on race,color,or national origin. GF�ntC�I£.L.l�I!C.Nf 4�i c:�!.Sn <br /> sign �� �u,•,,,���:�- 0 �l �-t � <br /> here Authorized Sig a re Title �ate <br /> FC7R C�7i1NTY 7Fi�ASURER RECOMMEN�ATION � <br /> APPROVAL COMMENTS: � �� <br /> ❑DISAPPROVAL <br /> ` ignature of County�Treasur� er Pate� / <br /> FOR COUNTY BOARD OF E�UALIZATION USE ONLY <br /> �PPROVAL COMMENTS� <br /> ❑DISAPPROVAL <br /> ��—�:�-•— <br /> uthorized ignature D�te <br /> Nebraska Departmenl of aevenue Aulhorizetl 6y Ne6.Rev.Stat.§§77•202(1)(c)antl(d),and 6�-3,165,end 60-3,189 <br /> 96-253-20p6 Rev.e-2011 5upersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A CbPY FpR YOUR RECORDS. <br />