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+d^ —_— 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 ❑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,State,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;PD Box 1009,Grand Island,NE 68802-1009 <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,it necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br />• <br />• <br /> if Newly Purchased <br /> Ford E250 2014 Van 1FTNS2EW9EDA90337 11/4/2014 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> A ricultural/Horticuhural Educational Religious as indicated? <br /> 9 ❑ ® 9 ❑Charitable El <br /> Give detailed description of use,including an explanation if multiple use classifications exist: 0 YES ❑NO <br /> Transport hospital equipment and patients between buildings. No,give percentage of exempt use: <br /> It Transport cash bags to bank and back. <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 employment based on race,color,or national origin. <br /> sign `ulJl r <br /> Gl9T President 11/5/2014 <br /> here I Authorized Signature Title Date <br />• FOR COUNTY TREASURER RECOMMENDATION <br />• <br /> Ab <br /> PPROVAL RECEIVTS: AA-0 A? <br /> S.S 77-20•? <br /> ❑DISAPPROVAL <br /> NOV 1 0 2014 G• oi°aoe.X-, he-��zee <br /> •11 Si nature oftounTy Treasurer Date <br /> 1 e1+�` a :0."D OF EQUALIZATION USE ONLY <br /> 'AND ISLAND NEBRASKA <br /> APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> ' /h /h-` alt!/goid <br /> Authorized Signature Da <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.H77-202(1)(0 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 />