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sham Application for Exemption FORM <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> *To be flied with your county treasurer. <br /> •Read instructions on reverse side, <br /> Applicant's 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(speedy): <br /> City State Zip Code State Where Incorporated <br /> WOOD RIVER NE 68883 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Title Name,Address,City State,Zip Code <br /> Please see attached. . . <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make I ModelYear Body Type Vehicle lD Number Date of Acquisition, <br /> It Newly Purchased <br /> GMC 1991 Sierra 1GTEK14KXME516506 <br /> Ford 2007 Freestar 2FMZA52247BA02760 <br /> Ford 2011 Cutaway 1FDFE4FS5BDB22694 <br /> Dodge-Braun 2014 Wagon 2C7WDGBGOER220305 <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: [j'ES ❑NO <br /> If No,give percentage of exempt use: <br /> The general use of vehicles is to transport residents to <br /> medical appointments, to and from hospital <br /> pp pital stays and <br /> recreational trips such as State Fair and parks. <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 /> signs <br /> hereAature . Title 1--14 <br /> Aumoriz attire Tide Date 5n_ati m <br /> rr�� FOR COUNTY TREASURER RECOMMENDATION <br /> elraPROVAI RECEIVEDCOMMI NTS: z' Ir77 4704.2 <br /> ❑DISAPPRCVAL <br /> DEC 8 2014 tY <br /> i1 Signature of County Treasurer Date <br /> +tAtl CpltluTy FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> TREASURERS OFFICE <br /> GRAND ISLAND,NEBRASKA <br /> %APPROVAL tA3MMENTS: <br /> ❑DISAPPROVAL i <br /> �/ �/. , —13.r5 <br /> thori F gn at <br /> .1 r Date <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet.§§77-202(1)(e)and(d).and 60-3.195,and 60-3,189 <br /> 96-253-200e Rev.8-2011 Supersedes 9&253-2006 Rev.5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />