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r��- 5d���a 1�l ,�' ��- � � i �- <br /> �✓fll r <br /> f ��� <br /> � Application for Exemption � FORM <br /> Nebraska DepartmenY of <br /> R E��V E from Mator Vehicle Taxes by Glualifying Nonprofit Organizations 4 5„7 <br /> •Tp be filed with ypur cnunty treasurer, <br /> �Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Good Samaritan Society-Wood River <br /> Q Npnprotit <br /> Street or Qther Mailing Address Gounty Corporation <br /> 1401. East St xail <br /> �pther(SpeCify): <br /> City State Zip Code State Where Inwrporated <br /> Wood River NE 68883 NE <br /> IDENTIFY OFF'ICER5,DIRECTORS,OR PAHTNERS qFl"HE NpNPFi4FIT ORGANIZATION <br /> Titl� Name,Address,City,State,Zip Gode <br /> Please see attached. . . . . . . <br /> p�SCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registratiqn Oate or <br /> hllotorVehicle Mske ModelYear BodyType Vehide ID Number paTe of Acquisition, <br /> if Newly Purchased <br /> Ford 2011 Cutawa 1FDFE4FS5BDB22694 <br /> Exempt Uses of Motor VBhicle: Are the mator vehicles used exclusively <br /> ❑Agricultural/Morticultural ❑Educational �]Religious ❑Charitaqle ❑Gemetery as indicated? <br /> Give detailed descriptian ni use,induding an explanation if multiple use classifications exist: �YES �NO <br /> Skilled nuxsing facility owned and apera�ed by The Evangelical � <br /> � <br /> Lutheran Good Samaritan Society -- Non profit starus <br /> F�B - 9 2012 <br /> Under penalties vf law,f declare that I have examined this application and that it is,to the best nf my knowledge and b lief,true,comple�r�dEqr��ryfy <br /> also declare that I am duly authorized to sign this ex�nption application,and that the organization owning the above-lis d property dp�a���ri�8 t�FIC� <br /> in membership or employment 6ased on race,color,or national origin. GRAN�tSLFlPJf:�,N°�Bk=<,4!<.SA <br /> s i g n � " -��,�,� � 9 a_. <br /> here �ulhOriz�d t Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> [�APPRUVAL COMM�NTS: %//����I��_ '��� `'�O� <br /> ❑D15APPROVAL <br /> . `'J `�7 ��7 -J-�. <br /> Signature of County Treasurer Date <br /> FpR COUNTY BOARD OF EQUALIZATIpN U5E ONLY <br /> �APPROVAL CbMMENTS: <br /> []DISAPPROVAL <br /> ����ll�. <br /> uthorized ignat date <br /> Neb�aska Oepertmem of Ravenue AUthorized by Ne�.FiOV.SIaL§§"l7-202(1)(C)8rld(d),8nd 60-3,185,and 60-3,189 <br /> 96•253-2006 RBV.8-2D11 Suparsedes 96�253-2�06 Rev.5��2009 <br /> PLEASE RETAIN A COPY�OFi YOUR RECORDS. <br />