Laserfiche WebLink
i!'L — 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 /> Applicants 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 /> I 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 Type Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> DODGE 1999 CARAVAN SPORT 2B4GP44R0XR207365 <br /> GMC 1991 SIERRA IGTEK14KXME516506 <br /> FORD 2011 CUTAWAY 1FDFE4F55B0622694 <br /> FORD 2007 FREESTAR 2FMZA52247BA02760 <br />• Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 111 Agricultural/Horticultural ❑Educational ®Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 1A1 YES ENO <br /> • The general use of vehicles is to transport residents to If No,give percentage of exempt use: <br /> medical appointments, to and from hospital stays and i <br /> recreational trips such as State Fair and parks. <br /> P P <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 /> here ,AUthorized ig ^V.o/ 1- Title :u.. Date <br /> FOR FOR COUNTY TREASURER RECOMMENDATION <br /> 2.APPROVAL` RECEIVED COMMENTS: -L_ '�""T 0../2-1-'1"d '411-°51 5- 77' C„.2 <br /> ❑DISAPPRCVAL <br /> D EC [ "1 <br /> c)1 a ad-E /— 3 /4/ <br /> • Signature of rTreasurer Date <br /> HALL COUNTY <br /> TREASURERS OFFI2- <br /> a R COUNTY BOARD OF EQUALIZATION USE ONLY <br /> bhfANU ISLAM),el -- - KA <br /> yAPPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> • / fL * �� /—/ a0/4t <br /> •Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-202(1)(c)end(d),and 60-3,185.and 603,189 <br /> 96-253-2006 Rev.6-2011 Supersedes 96-253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />