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zo� 2 �TQ�FILE W�-�� Ex�mptian Applica�ion �o�r� ��p for ax Exemptian on F�ea] and p�rsonal Property by Qualitying �rgani�atissr�s �S� S�� Resd instructians on reverse 3ide. F�ifure to properly complete or fi{e this appiicatian in a timely manner shail resuli in a�isapprovaf of the exemption. 'am ��f Orgar,ization G'ounty Geunry No. -Fype of Ovmership � EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY Hall qp � �Jonprolit Carporatior � Sfate`Nhare Ir,c�r x�ra?ed � Other(Sper.ilyl treei or ptYiPr�.9ai:i��Addrees � 4p75 TIMBERLINE ST NEBRASKA Gity Stato 7_iP Cnde AQ{U8�ti�3I'JE Psrcel or Lacation la Num�er GRAND ISLAND N� 68803 516,855 l.egal deseripticn o?teal propetty and genara;desoription oI a11 tangible p�rson�J proparty,exaept liaensed mator veh�cies: GOOD SAMARI7AN 5UB LT 2 BLK 1 (4055-4Q59 TIMBERLIN�)#40D13704fi GOO�SAMARI`f�AN 5U� LT 3 BLK 1 (4071-4075-4079 TIMBERLINE)#4Q013705�} GOOI�SAMARITAN 5UB LT 25 BLK 1 4911 T�RRACE CIR #400137585 MAINTENANCE BUILDING ANb STORAGE SHED 7it)s ai Dtficers, NarrEe Directats,or Partners Address,Cit�y,State,Zip Cade ---�-.-•_.m ��•-•------------��.-•-�g-.••-------..•.•••••••••----- ----•-•_•••-•--••--•----------------------------------•.•-••••�-. •--. -•-••--•------------------------- See attached list" Pi'epert�j dESr.ribad nhove is used iri the fol3nwin�eacempt cate�r�ry(pieas�rrisrk the applicaW°bexes): �AgrculturaiiHcr.iculiural Society' � Educational �Religious �Gharit3kila �Cametery� Giv�e datai!ed descrtptiort of ha use ot tha propeKy: This property is ovned by a charitable, religious organizatian. This is a �nulti-level retirement village, praviding Skilled Nursiug l�acilitp houses. (l�censed for Medicare and NE Medicaid), Licensed Assisted Llving Facility and Senxo� Apartments writh Serv3ces, serving age restricted senia�s age 55 and over. Incl.udes svcial programmi.ng in a Christian environment "Agriculturai/Florticuftural Suciety does not need to compiete the foliowing questions. Jr ali q1 the property usad axc�usively as desaibed abova? S�YES �NO Is�p:�rtic�n ni the prcr}r"ty used�ur the sai�01 ak:oha!ic beuerages? �YtS �ND N Ye;,sta4e the nurnher o'hntir:per k�eek Is the prap�rly awned or used py an organizadian which discr�iniratas in m�m6ership or empl�_�,yment based on raae,:.cior,or naticna!ori�in? �Y�S �PJO Undar penalties cf law,I de:�are that f have examined this exemptioil app;ication and,to the best ot my knaw!edge ard beliel,it is canect and rnm��ists.I also declare that 1 arn culy authrrized to sir,n th;s exernrilion ap�licatinn. ��°..' �� _ Egecutive Dxrector l " � �fw± orized 5ignature Title Date ��r��r T�ID SC�lIIeldC� °•�--•.,�_�_.--•-----_.�-•-_�_--.._-••••-- �••_•••-•�------------�.•••••••••••--.� -••-•--••••-------------------------------_.-••••••-.'.� �--- -- FOR COUN'TY ASSESSOR'S RECOMrv9Eh7�ATIOPJ �APWHOV.�1L CDMAdENTS: 1 �`- Q� L,i A?PAJ�lAL OF A POR71�N C DISAPF'RCiVAL . � Siqr.ature o� e niy Assessor patw ------------•.--..�_.__-------- -°•�••----------°°--------•--•••••-•--------__�_..•.-••-•._.--------- -------••-••••.•--- •--------�.-._-••••--°-°-•-°----------------------------•.--.••-••-.�.._�_ FOI�CQUNTY 9dA OF EQUALfZATIQN USE ONLY I declare tiiat,[u ihe k�e:t r}i my knr�wiedy°and h�nlief,the rJeterrninaticn hershy r,ade hy,he C1�iir�ty Poard nt Fqualizalian is�errect pursuant to the lav.'s of the.Sttte of Nebt�:ka. � APPWOVED COMMEMl'S: � -- ? A?PflO�IAI.OF A P!7R71r3N •••---------- ••----_._.--••••-..._ _--•�••�•••••-...--•.•- --- -•.•••� •••--••_-°--•�-•��_---------••--'•°-°_•.••--_-�-••-••_-_ C L715Af'PRGV�D �� Sic�nsture uf aurty ar emb Oa.e iebraska GspartrnanC ur aev�nue h C�y/� ev.�tet.§77•t02.0� 36-135•7999 Re¢7-�010 S4�"ereedes 96•735•;999 FIEV.17-'0�6 U� �+Y,��'�� PLEA�E IvIAKE A CQPY FUF3 YOLfR R�CORDS HALL GpUIVTY HSSESS��t GRANDISLANQ,N�8RN5KA