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2012 <br /> .. — .,tn$�F���[�N1�'�I-� Ex�mption Appiicatiar� ����i� . <br /> YOUR farl'ax Ex�mption on Fteai and Persanat property hy Qualifying arganizatians ��.� <br /> OUNTY ASSESSQR Read instructiuns an revetse sida. <br /> Faiiure te praperty compiete ar fife ihis appiication in a timely manner shalE result in a disapprovaf of the exemptian. <br /> ' 'a e of prgarization Counry Ccuny fJa. '(ype��f U�r�r:ership <br /> LUTHERAN GOO� SAM SOCIETY Hall 40 � PlonprclitCorWuratior, <br /> State'Nh�re Incar�nr�ted � �iner(Speciiyl <br /> �treet r QtFi=r 1.1ai:inp AfJdre=s C <br /> C/O GOOD SAMARITAN 50CIETY°�NOOD RIVER NEBRASKA <br /> 4,i�, Stato �ip Cnde Actual Value Parcel or Lacati�r.ID Number <br /> WDOD RIVER N� 68883 1,397,4fi3 400179571 <br /> Le�al dey,ripticn of re�l nraperty and aEnera;description af all t�ngible parsonal p!op�Hy,except licansed moto'vehicies: <br /> VILLAGE OF WOOD RIVER EAST NQRTH LAWN ADDITION BLK 2 (NURSING HOME) <br /> TiEle af afficers, <br /> Name Directors,or Partners Address;City,State,zip Cvde <br /> LE a{�-h��e� �i5{'�v� �w.. <br /> prnperty c:escriiiad�hove is u�zd iri the ipllow;in�exerript�te�r�ry(piea�e rnark the ap�lica6la b�:xes); � <br /> �A�r!culturaiiHcr;iculiural Sbciebf � Educational �Reli�ious �harit.bla �Cemeter� <br /> Gi�e a d�tsi!ed dascriptian o1 tha use of tha propeKy: <br /> �I��pc,. N�,fS�r�q �t�C•�t� <br /> J <br /> "AgricuituralMorticultural Society daes nut need to romplete the following question�. <br /> :t all oi the prqperty usad exGUSively��dss�ribed abova7 �YC.`'i ❑NO <br /> (r a p�rNor ut iFie prnr�erry used inr 1Yir:sa;e of alc�huiic heveray�s? �Y�S �NO I1 YEfi�sT;aie the nurrihe�ni hours per wer;k <br /> Is the properry nwned nr used by an organizaiian which discr:mirates in <br /> membership or emplr,yrrent bused on raoe,color,er naticna�oripin? �Yc5 �NO <br /> Undsr penalties of lasv,I de�lare that f have examined this cn:�mption appiication and,to the 6est of my Icnow:edge and�eliet,it is correct and <br /> compiete.I a;sa deciHre t�at 1 arn culy authcrized t�slrn th:s e�ernptian applicatin:�. <br /> . r- <br /> ��C��°I � ,` �1CtCu'�'l�l� �r�[.�'D•r �� '"�i7"'� <br /> 1.v��r� �AuihoriZadSi ure "fitle date <br /> 1� 1 <br /> -•-•----°-----••--•._--�.-••�••__---W•-__ -•••.•-.•-..�- -----------•----_.•••-•--•-°-•---�-----------------------------�--�---°---•-••.•...............� <br /> FOR C(IUNTY A55ESSOR'S RECpNfMEN[IATiDfd <br /> � ---- <br /> �APPRQV.��L GOMMIEIJT.i: �� w�a �.,,l�I\X � 1_�r1. ��C� <br /> L; A?pROVAL OF A PORTlbN <br /> C DISAP?RPVAL �'l�`�~�o <br /> Si.�natur Counly Assessor Date <br /> -- ---•-•-------------•-••-._-------••-•-••�•-�-----_��.�-°-•----•,--------------------••••• .......�....••----------------------------------...-•-•---•,-°-•--------------------------•-------------_-�-••-••••••••..••- <br /> I- ---- - <br /> FOR COl1N'fY�f3AR OF EQUALlZATIah USE ONLY <br /> I decfare that,to iFie:k�est at my knrawledg�and�eliel,the delerrrun2tion h.=,rehy r�arJe 6y,he County Eoard u1 F.qualizaTinn is�errect pursusnt <br /> io the law'e of the�tate ot Nebraska. <br /> � A���p���� CDMMEN'1'S: <br /> � A?PFipVP.L.QF A PGATIpN --------- �_..__..—..---- ----_.•-_•- •_••-_--_._--------------------------- --- .� <br /> ••• .••-- -- --°--•-- °------- <br /> ❑ uisA��ROV�o <br /> . ���,� � ./,� <br /> .iynsture of ourty ard 9AmliNr [7a".e <br /> dabreska�apar;men(uf�evenue . t �d g77�202,01 <br /> SG-135•7999 HeV.7-c010 Supersedes 95-135•1999 Rev.11-?008 <br /> NALL COUNTI�` ASSE�SO� <br /> PLEASE MAKE A COPY FpFi YQUR FI�CORDS GRAND ISLAN�,h��RASK/� <br />