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Application for Exemption FORM <br /> N Department E <br /> REVENREVEfrom Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> UE •TO be filed with your county treasurer. 457 <br /> •Read Instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Good Samaritan Society Grand Island Village El 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 w <br /> The Name,Address,City,State,Zip Code <br /> See Attached List <br /> • <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> *Attach an additional sheet,If necessary. ' <br /> Registration Date or <br /> Motor Vehicle Make Model Veer BoryType Vehicle ID Number Date of Acquisition, <br /> N Newly Purchased <br /> Ford 2003 Windstar 2FMZA51443BB51330 <br /> Ford 2010 Arneribans 225 1FDWE3FLIADA61698 <br /> Dodge 2012 Grand Caravan 2C4RDGBGXCR298629 <br /> Dodge 200s Ram 1500 4X4 JT4RN13PXM6025935 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural ❑Educational ®Religious ®Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: - EYES ❑NO <br /> The vehicle will be used to transport residents that live in the Retirement Apartments, <br /> Assisted Living Facilities, and the Skilled Nursing Facilities. The vehicle will transport If Nq give percentage of exempt use: <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 a <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 I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate <br /> in members •IF-mployment based• ,race,color,or national origin. <br /> sign 2 " 40 Administrator 1/17/13 <br /> here ,Aulhodz-• attire Title Date <br /> FOR COUNTY TREASURER RECOMMENDATION <br /> VAPPROVAL RECEIVED COMAENTS: `"'i"t/21-0-) 10.SS• 77— '°-z <br /> • <br /> ❑DISAPPR)VAL <br /> 4A11 18 8 2*# s_>_ .y� / /�i3 <br /> • signatu f umy Treasurer Date <br /> AL OR COUNTY BOARD OF EOUALIZATION USE ONLY <br /> GRAND ISLAND.NEBRASKA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL ,I <br /> G? /g <br /> /`. /1,</� .=�� <br /> T honied ignature' Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d).and 803,185,and 60-3189 <br /> 98-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />