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+��nt 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 /> 4110Applicants 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 /> ❑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 <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 Year Body Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> Ford 2003 Windstar 2FMZA514438B51330 <br /> Ford 2010 Ameritrans 225 1FDWE3FL1ADA61698 <br /> Dodge 2012 Grand Caravan 2C4RDGBGXCR298629 <br /> Dodge 2005 Ram 15004X4 1B7HF16Z81S707690 <br /> Ford 2013 Supreme450 1FDFE4FS2DDA26721 <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: El YES ❑NO <br /> �The vehicles will be used to transport residents that live in the Retirement Apartments, <br /> ssisted Living Facilities and the Skilled Nursing Facilities. The vehicles will transport If No,give percentage of exempt use: <br /> residents to their doctors and other medical appointments. They 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 p <br /> Under penalties of law,I declare that I have examined this application and that his,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 />• <br /> in me rshi or employment b d on race,color,or national origin. <br /> Sign , "\Q_PJ�0,— Administrator 11/15/2013 <br /> Auth�ature Title Date <br /> here g <br /> RECEIVE.. fYTRFlze3 �3 RECOMMENDATION N ON A-1.4.-1. en-P' <br /> fl APPROVAL COMMENis: <br /> ❑DISAPPROVAL NOV 1 9 2013 <br /> IlliB SLUrEa$ I'8iggnnafore of County Treasurer Date <br /> BRAND ISLAND.N BOARD OF EQUALIZATION USE ONLY <br /> ) APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> I'Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Ned Rev.Slat.§§77-20211)(c)and(d),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 />