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ea+iLZ Application for Exemption FORM Nebraska Department of REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 •To be filed with your county treasurer. •Read Instructions on reverse side. •Applicant's Name Type of Ownership Good Samaritan Society Grand Island Village ®Nonprofit Street or Other Mailing Address County Corporation 4075 Timberline Street Hall ❑Other(specify): City State Zip Code State Where Incorporated Grand Island NE 68803 South Dakota IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION This Name,Address,City,State,Zip Code See Attached List DESCRIPTION OFTHE MOTOR VEHICLES •Attach an additional sheet,If necessary. Registration Date or Motor Vehicle Make ModelYear Body Type Vehicle ID Number Date of Acquisition, if Newly Purchased _ Ford Supreme 2013 BUS 1FDFE4FS2DDA26721 • Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑ Agricultural/Horticultural ❑Educational ®Religious ®Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist ,1 YES NO • The vehicle will be used to transport residents that live in the Retirement Apt.,Assisted Living If No,give percentage of exempt use: Facilities and the Skilled Nursing Facilities.The vehicle will transport residents to their doctors and other medical appointments. It will be used to transport resident to and from the hospital. In an emergency, it would be used to evacuate residents to safety. It will also be used for field trips, grocery shopping, sight seeing, concerts, activities and other outings. 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 also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment ased on race,color,or national origin. sign Administrator 3/11/2013 here Auth Signature __. Title Date _. FOR COUNTY TREASURER RECOMMENDATION Et<PPR@ AL RECEIVED CO 1IMENTS: ICe ' t /9e r 4' 't-77-. e51.2.2 ❑DISAPPROVAL MAR 1 22413 Signature of County Treasurer Date , RSrOFRIC! FOR 1 OUNTY BOARD OF EQUALIZATION USE ONLY GRAND NO amp.NCDRMICA APPROVAL COMMENTS: ❑DISAPPROVAL ___. _ thoriz-.Signature — Date Nebraska Department of Revenue Authorized by Neb.Rev.Stat gg 77-202(1)(c)and(d),and 60-3,165,and 60-3,189 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.