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Application for Exemption FORM <br /> Nebraska 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 Grand Island Village ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 4075 Timberline Street Hall <br /> Daher(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 Veer Body Type Vehicle ID Number Date of Acqulstion, <br /> N Newly Purchased _ <br /> Ford Supreme 2013 BUS 1 FDFE4FS2DDA26721 <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 it multiple use classifications exist ®YES ❑NO <br /> The vehicle will be used to transport residents that live in the Retirement Apt., Assisted Living <br /> If No,give percentage of exempt use: <br /> Facilities and the Skilled Nursing Facilities.The vehicle will transport residents to their <br /> doctors and other medical appointments. It will be used to transport resident to and from the <br /> hospital. In an emergency, it would be used to evacuate residents to safety. It will also be <br /> used for field trips, grocery shopping,sight seeing, concerts, activities and other outings. <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 erzemption application,and that the organization owning the above-listed property does not discriminate <br /> in membership or employment on race,color,or national origin. <br /> sign , Administrator 3/11/2013 <br /> here Auth Signature Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> l <br /> APPROVAL RECEIVED CO WENTS: niCenspt r , /5-s at-77- .y <br /> ❑DISAPPROVAL MAR 1 2 2013 <br /> \—'� )/°feria' <br /> TRE`gs�� „ <br /> Signature County Treasurer Date <br /> GRAND r UR R OFFICE FOR BOUNTY BOARD OF EQUALIZATION USE ONLY <br /> VAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL .l <br /> Tthorized Signature Date <br /> Nebraska Department of Revenue Authorized by Net.Rev.Stat.§§77-202(1)(0)and(d),and 60-3,185,and 663,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />