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e <br /> ��— Application for Exemption FORM <br /> Nebraska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •TO be flied with your county treasurer. <br /> •Read Instructions on reverse side. <br /> •Applicant's Name Type of Ownership <br /> Good Samaritan Society Grand Island Village ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4075 Timberline Street Hall ❑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 /> Title Name,Address,City,State,Zip Code <br /> See Attached List <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year BodyType Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Ford 2003 Windstar 2FMZA51443B851330 <br /> Ford 2010 Ameritrans 225 1FDWE3FL1ADA61698 <br /> Dodge 2012 Grand Caravan 2C4RDGBGXCR296629 <br /> Dodge 2001 Ram 1500 4X4 JT4RN13PXM6025935 <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 it multiple use classifications exist l YES ❑NO <br /> The vehicle will be used to transport residents that live in the Retirement Apartments, <br /> If No,give percentage of exempt use: <br /> �lssisted Living Facilities, and the Skilled Nursing Facilities. The vehicle will transport <br /> residents 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. The 2 passenger truck is used for maintenance around the facility, picking up <br /> and hauling tools, supplies, parts, equipment, snow removal, landscaping, furniture,water g <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 t t I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in member .or-mployment ba�race,color,or national origin. <br /> sign 9tA, 7 Administrator 1/17/13 <br /> here 11 Authori.-• '. ature Title Date <br /> y�q FOR COUNTY TREASURER RECOMMENDATION <br /> PPROWL RECEIVED COM AENTS: `7 ` /21--i") ,}SS 77— <br /> ❑DISAPPR OVAL <br /> 4111* t 8 RS /-4,7":—/a <br /> Signatu f nty Treasurer Date <br /> HALL COUNTY OR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURE <br /> GRAND ISLAND,NEBRASKA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> ■ <br /> • <br /> a /,.g <br /> authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d),and 60-3,185,and 60-3,189 <br /> 96.253-2006 Rev.8-2011 Supersedes 96-253.2008 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />