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cAbiLlk <br /> NeeCra Depa—nmz.— Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations A�7 <br /> •To be tiled with your county treasurer. Y <br /> •Read instructions on reverse side. <br /> Applicant's Name Type of Ownership <br /> • GOOD SAMARITAN SOCIETY - WOOD RIVER G Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1401 EAST ST HALL ❑Other(specify): <br /> City Slate 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 /> See Attached. . . , <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 Acquisition, <br /> if Newly Purchased <br /> DODGE-BRAUN 2014 WAGON 2C7WDGBGOER220305 <br />• <br /> I i <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> 0 Agricultural/Horticultural ❑Educational Di Religious [11 Charitable ❑Cemetery as indicated? <br /> rr��CCYEREGEW ED <br /> Give detailed description of use,including an explanation if multiple use classifications exist; LT <br /> 0 The general use of vehicles is to transport residents to No.gi epercen aged exempt use: <br /> medical appointments, to and from hospital stays and l,r'p 2 "' 2014 <br /> recreational trips such as State Fair and parks. <br /> HALL COUNTY <br /> TREASURERS OFFICE- <br /> GRAND ISLAND,NEBRASKA <br /> Under penalties of law,I declare that I have examined this application and that a is,to the best of my knowledge and belief,true,complete,and correct.I <br /> also declare that l am duly authorized to sign this exemption application,and that the organization owning the above-listed properly does not discriminate <br /> in membership or employment based on race,color,or national origin. <br /> here `Authorized RI:ture - ' — <br /> Title Date <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> APPROVAL COMMENTS: y«�f /6 �� �S` 77- , ,,o a <br /> ❑DISAPPROVAL <br /> Oy,U'./, -2f1/7, <br /> /Sign of County Tre%er Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> XAPPROVAL COMMENTS: • <br /> ❑DISAPPROVAL <br /> • Pe-CA-Q _ 3/45/�� <br /> Authorized Signature Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.H77-202(1)(0 and(d),and 60-3,185.and 60-3,189 <br /> 96-253-2006 Rev.6-2011 Supersedes 95253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />