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s " <br /> to If <br /> +nn...--z. - Application for Exemption FORM <br /> Nebraska Department W <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be filed with your county treasurer. <br /> mEcimnal •Read Instructions on reverse aide. <br /> Applicants Name Type of Ownership <br /> SAINT FRANCIS MEDICAL CENTER ®Nonprofit <br /> Street ar Other Mailing Address County Corporation <br /> 2620 W FAIDLEY AVE PO BOX 9804 HALL ❑Other(specify): <br /> City State Zip Code State Where incorporated <br /> GRAND ISLAND NE 68802 NE <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 68602 <br /> CEO-CHI Health Cliff Robertson,MD;12809 West Dodge 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 /> if Newly Purchased <br /> SEE ATTACHED LIST <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgricWhaabHoribultural ❑Educational ®Religious El Charkable El Cemetery as ltd ated? <br /> Give detailed dissodption of use,khciudmg an expfanalon it multiple use classifications exist ®YES LINO <br /> Transport hospital equipment and patients between buildings. <br /> If No,g ve percentage of exempt use: <br /> Transport cash bags to bank and back. <br /> Transport patient food and laundry between buildings. x <br /> Under penalties of law,I declare that I have examined this application end that If Is,to the best of my lehovdodge and belief,sue,complete,and coned.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization ownIng the above-stied property does not discriminate <br /> In membership or employment based on race,color,or national origin. <br /> sign <br /> here ••,Signature Title -!ar-39 p.- r�/o r Dale <br /> FOR COUNTYTREASURER-RECOMMENDATION T <br /> �PROVAL RECEIVED COMIENTS: derilt-rilAtr se...":s 1r77 452'2' <br /> ❑DISAPPROVAL - <br /> DEC 1 5 2014 ,�f dr /-7-i.< <br /> Signature of Coup Tieaeurer Date <br /> HALLCOUNTY FOR CO.INTY BOARD OF EQUALIZATION USE ONLY <br /> lntsbuartrS OFrICE <br /> GRAND ISLAND,NEBRASKA <br /> 11,1APPROVAL COMMENTS: <br /> ❑DISAPPROVAL . <br /> . lei.'! AB ./-/3-Zs <br /> 7.rl.:.Sign: Date <br /> Nebraska Department of Revenue Authorized by Nets rev.Slat.§8 77-202(11fc)and Id),and 60-3,t85,and 603,109 <br /> 962552005 Hew.8-2011 Supersedes 902532000 Rov.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />