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020/3 <br /> -r Z- 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 /> azimirci •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> ood Samaritan Society Grand Island Village Nonprofit <br /> eel or Other Mailing Address County ®Co poration <br /> 4075 Timberline Street Hall County ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand island NE 68803 South Dakota <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> The Name,Address,City,State,Zip Code <br /> President and chief Executive Officer Mr.David J.Horazdovsky 1112 East Dove Trail;Sioux Falls,SD 57108 <br /> Chairperson Ms.Patricia K.Haugen 900 E.Justin Drive;Sioux Falls,SD 57108 <br /> First Vice Chairperson Mr.Neil L.Gulsvig 2306 Eagle Valley Lane;Wausau,WI 54403 <br /> Member-Executive Committee Mr.Christopher T.Johnson 12880 53rd Street North;Stillwater,MN 55082 <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 /> H Newly Purchased <br /> Dodge. 2012 Sport Van 2C4RDGBGXCR298629 10/09/2012 <br /> Dodge-• .7oeI rgq/area'..cite, /97//F/4ZS/57o71go <br /> _ <br /> Exempt Uses of Motor Vehicle: I Are the motor vehicles used exclusively <br /> Agricultural/Horticultural ❑Educational ©Religious ®Charitable ❑Cemetery as indicated? <br /> ❑ <br /> Give detailed description of use,including an explanation it multiple use classifications exist: ,/YES ❑NO <br /> e vehicle will be used to transport residents that live in the Retirement Apartments, If No,give percentage of exempt use: <br /> isted Living Facilities, and the Skilled Nursing Facilities. The vehicle will transport <br /> esidents to their doctors and other medical appointments. It will be used to transport <br /> residents to and from the hospital. In an emergency, it would be used to evacuate residents <br /> to safety. It will also be used for field trips, grocery shopping, sight seeing, concerts, and <br /> other outings... <br /> • I <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 l 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 Administrator 12/18/2012 <br /> here Au d Signature Title Date <br /> /�`[y . FOR COUNTY TREASURER RECOMMENDATION --f <br /> APPROVAL ' `ECEIVED COMMENTS: �-"0"'" ,S 4 SS 77°r°°2" <br /> ['DISAPPROVAL DEr 2 6 ^,.m' _ 1�f� ,,/�D <br /> HALT-C'1tNNTY •Signature of County Treasurer Date <br /> i T't c.,ipc.g,5 r16rlCP <br /> ertAi1)Ir.'AND,NE3IRAsKA F�{iCOUNTY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL .r, COMMENTS: <br /> I <br /> DISAPPROVAL / <br /> is,1lc - : S&ea �I'._ 'ft ,_/4---074c# <br /> Authorized Signatu - Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Shat§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.6-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />