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� F� WI7H Exemption Application FORM Yp farTax Exemption on Real and Personal Property by Glualifying Organizations 45� C U TY 5S�5SOR Read instructions on reverse side. � Failure to properly complete or file this application in a timely manner shall result in a disapproval of the exemption. e e of anizat n County Gvunry No. 7ype of Ownership S INT C15 MEDICAL CENTER HALL 40 � NonprofitCorporation eet or Other Mailing Address State Where Incorporated � Other(Specify) PO BOX 9$04-2620 W FAI�L�Y AVE NEBRASKA Gity State Zip Code Actual Value Parcel or Location ID Number GRAND ISLAND NE 68802 $51,132,520 SEE ATTACHEb Legal description of real property and general description of all tangible personal properry,except licensed motor vehicles: Title af Officers, Name Directors,or Partners Address,City,State,Zip Code Dan McElli ott President PO Bax 9804 Grand Island NE 68802 Mark Miller Chairperson 617 W 3rd St; Crand Island, NE 68801 Susan Kbeni Vice Chairperson 3p8 N Locust 5t•Grand Island NE 688D1 Timoth Knudsen Ex O�cio 704 AI ha 5t Grand Island NE 68803 Robert Lanik Ex-O�cio 555 S 70th St Lincoln NE 68510 Property described ahove is used in the tollowing exempt category(please mark the applica6le boxes): �Agricultural/Horticultural$ociety" � Educational �Religious �Charitable �Cemetery Give a detailed description of the use ot the properry: Used in daily haspital operations. '4gricultural/Horticultural Society dces nvt need to complete the following questions. all of the properry used exclusively as descrihed above? �YES �NO Is a portion of the prvperty used for the sale of alcoholic beverages? �YES �NO If Yes,state the number of hours per week Is the properry owned ar used by an organizafion which discriminates in membership or employment based on race,color,or nationel origin? �Y�S �NO Under penalties of law,I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is wrrect and complete.I slso declare that I am duly authorized to sign this exemption application. Sigrl � � /!: � here Authn zed Signature Title ❑ate FOR COUN7Y AS5ES50R'S RECQMMENpA710N �APPROVAL COMMEN75: �y(��,.�,��,� �� ❑ APPROVAL OF A PORTION ❑ DISAPPROVAL `� `� � \� Signature ounty Assessor Date F�R COUNTY BOA OF��UALIZH7tON US�ONLY I declare that,to the best oi my knowledge and beliei,the determination hereby made by the County 8oard of Equalization is correct pursuant to the laws oi the State ot Nebraska. �APPROVED C�MMENTS: ❑ APPRQVAL OF A PQRTION �'�� • , ��,� J� y ,,; � . ❑ DISAPPF�OVE� � ��"�� ignature o(Cou oar ember �C 2t �C Nebraska peparlment of Ravenue U L� h e -y N�.Rev.Stat.§77-202.01 96-135-1999 Rev.7-2tl10 Supersedes 96-135-7999 Rev,11-2DOB F�AL.I. G(�±�3L 4�, �,��SS�� PLEASE MAKE A COPY FOR YOUR RECORDS G�{�1NL��5��'�`�>�'°`B�'�'SKA