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..,.��- Application for Exemption FORM <br /> Nebraska Departmant of <br /> R,EVENUE from Motor Vehicie Taxes by Qualifying Nonprofit Organizations 457, <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> - Type of Ownership <br /> ApplicanYs Name <br /> Saint Francis Medical Center �Nonprofil <br /> County Corporation <br /> Street or Other Mailing Address Halt <br /> 2620 W�aidley Ave PO Box 9804 �Other(spenify): <br /> G,� State Zip Code State Where Incorporated <br /> Grand Island NE 68802 N�B� <br /> IPENTIFY OFFICERS,DIREC70R5,OR PAFiTNERS OFTHE NONPROFIT OFiGANiZATION <br /> Title Name,Address,City,State,Zip Code <br /> President Pan McElligott;PO Bax 9804;Grand Island,N�68802 <br /> Chairperson Susan Koeniq;308 N Locust,Ste 306;Grand Island.NE 68801 <br /> Vice Chairperson Paniel Naranjo;2929 S Locust St;Grand Island,NE 68801 <br /> Ex-O�cio Robert Lanik;694D O Street,Ste 200;Lincoln,N�6851� <br /> DESCRIP710N OF7HE M070RVEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> ModelYear Body7ype Vehicle ID Num6er Date of Acquisition, <br /> Motor Vehicle Make if Newly Purchased <br /> Buick 20D0 4 Door Sedan 2G4WS52J2Y1270818 7/17/12 <br /> Are the motor vehicles used exclusively <br /> Exempt Uses of Motor Vehicle: as indicated? <br /> ❑AgriculturaUHorticultural ❑Educational �Religious ❑Charitable ❑Cemetery <br /> Give detailed description of use,including an explanation if multiple use classifications exist: <br /> �YES �NO <br /> Patient Transport p� i����e of exem �5�: <br /> I'� <br /> Ju � 7 2012 <br /> Under penalties of law,I declare that I have examined this application and that it is,to the best of my k owledge and�' , � _ correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owni g the abc�l��� R5_a � i inate <br /> in membership or employment based on race,color,or national origin. <br /> i <br /> � �- %:� ;.r � . <br /> SIg11 �,,� � �� . <br /> here ��1zed Signature' Title Date <br /> FOR COUN7YTREASURER RECOMMENDATION <br /> APPROVAL <br /> COMMEN75: N�'� �� ���J <br /> �DISAPPROVAL <br /> � ��..�f �''���"� �.�7--�i� <br /> Signature of Counry Treasurer Date <br /> FOR COUNTY 80ARD OF�QUpLIZATION U5E ONLY <br /> �APPROVAL COMMEN75: <br /> �pl$APPRQVAL <br /> thonze ignature D te <br /> Nebraska IJepartment ot Revenue Authorized by Nab.Rev.StaL§§77•202�1)(c)and(d),and 60�3,785,and 60•3,189 _ <br /> 86-253-20D6 Rov.B-2011 Supersedes 96-253-2006 Rev.5-2o09 <br /> PL�ASE RE7AIN A COPY FOFIYDUR RECORDS. <br />