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s <br /> i`" <br /> item Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> • SAINT FRANCIS MEDICAL CENTER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2620 W FAIDLEY AVE PO BOX 9804 HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tale Name,Address.City,State,Zip Code <br /> • <br /> PRESIDENT DAN MCELLIGOTT; PO BOX 9804:GRAND ISLAND,NE 68802 <br /> CHAIRPERSON SUSAN KOENIG; 308 N LOCUST ST,SUITE 306; GRAND ISLAND,NE 68801 <br /> VICE CHAIR PERSON DANIEL NARANJO; 2929 S LOCUST ST; GRAND ISLAND,NE 68801 <br /> EX-OFFICIO ROBERT LANIK; 555 SOUTH 70TH ST;LINCOLN, NE 68510 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> [[k A <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticultural ❑Educational ©Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO <br /> If <br /> SRANSPORT HOSPITAL EQUIPMENT AND PATIENTS BETWEEN BUILDINGS. No,give percentage ot exempt use. <br /> RANSPORT CASH BAGS TO BANK AND BACK. <br /> TRANSPORT PATIENT FOOD AND LAUNDRY BETWEEN BUILDINGS. . <br /> Under penalties of law,I declare that I have examined this application and that it is.to the best of my knowledge and belief,true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> sign `fit r../ eul it/,Z„),7 <br /> here IAut Signature Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> [( PPHOV.L RECEIVED CON MENTS:�RE9" /—e y"rS 77—20.2-z <br /> ❑ DISAPPF OVAL Nov 2 J 2/'2 <br /> HALL COUNTY ,Signature of County Treasurer Date <br /> OFzozcs isL ND OFFICE pOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> D N�rzA� <br /> APPROVAL COMMENTS: <br /> ❑ DISAPPROVAL <br /> i <br /> • <br /> _ / at -!v 1-And oi, <br /> uthorized ”nature air Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),end 60-3,185,and 60-3.189 <br /> 96-253-2006 Ray.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />