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Ne^--Z-- Application for Exemption FORM <br /> braska Department of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be tiled with your county treasurer. <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> GOOD SAMARITAN SOCIETY-WOOD RIVER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1401 EAST ST HALL ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> WOOD RIVER NE 68883 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> Please see attached <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year _ Body Typo_.. Vehicle ID Number -I_ Date of Acquisition, <br /> -- - - - If Newly Purchased <br /> Dodge 1999 Caravan Sport 2B4GP44R0XR207365 <br /> ■ GMC 1991 Sierra 1GTEK14KXME516506 <br /> FORD 2011 Cutaway 1FDFE4FS5BDB22694 Febr 2, 2012 <br />• Ford _ 2007 _ Freestar 2FMZA52247BA02760 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturavHorticultural El Educational ®Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multlple use classifications exist: El YES ❑NO <br />• <br /> • Skilled nursing facility owned and operated by The Evangelical if No.give percentage of exempt use: <br /> Lutheran Good Samaritan Society-Non Profit Status. % <br />• <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- g la- 5- 1a- <br /> here Authorized Signet gq 7 Title Date <br /> \\\UUUtl <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> BIPPF OVAL RECEI■ `V OOMMENTS: 45 eer,Ige7/4 Ae't-1 AV—Cs 17— .70,2, <br /> ❑DISAPPROVAL DEC. R .,.? <br /> 6 <br /> It /� � ) <br /> Signature of County Treasurer Date <br /> RAI 1.COUNTY <br /> 7T!^ <br /> F JftEft3 OFFICE <br /> ru<,..,, ,. .,,,,5 agyunyizw FO i COUNTY BOARD OF EQUALIZATION USE ONLY <br /> APPROVAL COMMENTS. <br /> ❑DISAPPROVAL [ .t_ j <br /> • \ J��cCJoJ <br /> rAuthorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev,Stat,gs 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 />