Laserfiche WebLink
� �,v�� <br /> ��- Application for Exemption FORM <br /> Nebraska department of <br /> REVENUE �rom Motar Vehicle Taxes by Glualifying Nonprofit Organizations 45,7 <br /> •To be filed with your county treasurer. <br /> - •Read instructions qn reverse side. <br /> Applicant's Name Type of Ownership <br /> SAINT FRANCIS M�DIGAL CENTER �Nonprofit <br /> Street or Other Mailing Address Gounly Carporation <br /> 2620 W �AIDLEY AV� PO BOX 9804 HALL <br /> �pther(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> ID�N7IFY OFFIC�RS,DIRECTpRS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,Ciry,State,Zip Code <br /> President Dan McElligott: Pq Box 9804;Grand Island,NE 88802 <br /> Chairperson Mark Miller: 617 W 3rd St; Grand Island,NE 68801 <br /> Vice Ghairperson Susan Koenig: 308 N Locust 5t,Suite 30fi; Grand Island,NE 68801 <br /> Ex-O�cio Robert Lanik� 555 South 70th St; Lincoln,NE 68510 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additivnal sheet,if necessary. <br /> Registration Qate or <br /> Motnr Vehicle Make Mndel Year Body 7ype Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> See Attached <br /> Exampt Uses of Motar Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational �( Religious ❑Charitable �Cemetery as indicated? <br /> Give detail0d description of use,including an explanation if multiple use classifications exist: �YES �N� <br /> Transpart hospital equipment and patients between buildings. ����� <br /> Transport cash bags to bank and back. ir No,give�C 9 <br /> 1� <br /> Transport patient food and laundry between buildings. <br /> p�� � 2 2011 <br /> Undar penalties of law,I declare that I have examined this application and that iT is,to the best ot my knowledge and beli f,true,compip , �gp�r��Ip�p�C� <br /> also declare that I am duly authorized to sign this examption application,and that the organization owning the above-lista properry�1@�,f�clt��rf{ry�t¢q�gRASKA <br /> in membership or employment based on race,color,or national origin. <br /> Slgn �v� f� � �,�� ��� <br /> here Authorized Signatu Title Pate <br /> FOR COUNTYTREASURER RECOMMENDATIpN <br /> [r,�APPROVAL CQMMENTS: -S—S ��°°�J� <br /> ❑DISAPPROVAL <br /> � � --029— � <br /> Signature of County Treasurer � Qate <br /> FOR COUNTY BOARD�F EQUALIZATION USE ONLY <br /> APPROVAL CQMMEN7S: % <br /> i <br /> �pISAPPROVAL. , <br /> - r��� <br /> / <br /> �4 orized Signature Date <br /> Nebraska bepartment of Revenue Autnorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2D08 Rev.B-2011 Supareetlas 96-253-2006 Rev,5-2009 <br /> PLEA5�RETAIN A COPY�OR YOUR RECORDS. <br />