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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 filed with your county treasurer. <br /> "•" •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> Saint Francis Medical Center; dba CHI Health St. Francis ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 2620 West Faidley Avenue; PO Box 9804 Hall <br /> ❑Other(specify): <br /> City State Zip Code State Where Incorporated <br /> Grand Island NE 68803 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Title Name,Address,City,Slate,Zip Code <br /> President Dan McElligott,PO Box 9804,Grand Island,NE 68802 <br /> CEO-CHI Health Cliff Robertson, MD; 12809 West Dodget Road,Suite 368,Omaha,NE 68154 <br /> Board Member Barry Sandstrom;PO Box 1009,Grand Island,NE 68802-1009 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> H Newly Purchased <br /> Ford E250 2014 Van 1FTNS2EW9EDA90337 11/4/2014 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural/Horticultural 111 Educational DI Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: [AYES ❑NO <br /> Transport hospital equipment and patients between buildings. <br /> • Transport cash bags to bank and back. n No,give pe entage of exempt use: <br /> Transport patient food and laundry between buildings. <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 o employment based on race,color,or national origin. <br /> sign an a Ti 4C-tr- President 11/5/2014 <br /> here I Authorized Signature (/� tle Date <br /> [/� <br /> FOR COUNTY TREASURER RECOMMENDATION, IO�U / <br /> RIPPROVAL RECEI TS: • " !°- /✓- 55, '� 77-2p3 <br /> ❑DISAPPROVAL <br /> NOV 10 2014 n .sv g'''/ <br /> •Si nature oftowify Treasurer Date <br /> 1r� •D OF EQUALIZATION USE ONLY <br /> s :a LtJ:iG'ia����li <br /> AND ISLAND NEBR.gSI(A <br /> APPROVAL COMMENTS: <br /> ❑ DISAPPROVAL <br /> b /327A Authorized Signature Da <br /> Nebraska Department at Revenue Authorized by Neb.Rev Star§§77-202(1)(c)and IdI,and 60-3,185,and 60-3,189 <br /> 96-253-2006 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />