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File with Exemption Application FORM Your County for Tax Exemption on Real and Personal Property by Qualifying Organizations 451 Assessor Read Instructions on reverse side. Failure to properly complete or timely file this application will result in a denial of the exemption. Name of Organization County Name Tax Year Mid-Nebraska Foundation, Inc. Hall 2015 Name of Owner of Property State Where Incorporated Mid-Nebraska Foundation, Inc. Nebraska Street or Other Mailing Address of Applicant Total Actual Value of Real and Personal Property Parcel ID Number 216 N Denver $252,900.00 400149720 City State Zip Code Contact Name Phone Number Hastings NE 68901 Barbara Holsten 402-462-5107 ext 4 Type of Ownership ❑Agricultural and Horticultural Society ®Educational Organization ❑Religious Organization ❑Charitable Organization 0 Cemetery Organization Title Name of Officers, Address,City,State,Zip Code Directors,or Partners Ivan Klein Chairman PO Box 134, Gibbon, NE 68840 Dave Boehle Vice-Chairman 190 St Paul Rd, St Liborv. NE 68872 Allen Cetak Secretarv/Treasurer,2017 K St, Ord, NE 68862 Legal description of real property and general description of all depreciable tangible personal property,except licensed motor vehicles: Woodland Park Thirteenth Subdivision Lot 8 Blk 2 Lkut Rfe.t..,, 141.excco t%\J . • • • Property described above is used in the following exempt category(please mark the applicable boxes): ❑Agricultural and Horticultural Society IZ Educational ❑ Religious ❑ Charitable ❑ Cemetery JUN 1 8 2015 Give a detailed description of the use of the properly: HALL f • To provide training and housing for developmentally disabled citizens. They are trained and ec $ OJi po nupity kiwi rgi.by developing self-care and housekeeping skills. �- All organizations,except for an Agricultural and Horticultural Society,must complete the following questions. Is all of the property used exclusively as described above? ®YES ❑NO Is the property used for financial gain or profit to either the owner or owner or organization making exclusive use of the property? ❑YES ®NO Is a portion of the properly used for the sale of alcoholic beverages? ❑YES ®NO If Yes,state the number of hours per week Is the property owned or used by an organization which discriminates in membership or employment based on race,color, or national origin? ❑YES III NO Under penalties of law,I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and complete.I also declare that 1 am duly authorized to sign this exemption application. • sign k fie` 40 0 rzi CEO 6-16-15 here • Autho Signature Title Date Retain-a copy for your records. For County Assessor's Recommendation }-f W Approval COMMENTS: K__ FL, .ml ` t - -)� Cyr J. ❑ Approval of a Portion ❑ Denial Et .a.n k —A CC, C <<] Signature`of nt)'Assessor Date For County Board of Equalization Use Only I declare that to the best of my knowledge and belief,the determination made by the County Board of Equalization is correct pursuant to the laws of the State of Nebraska. ❑ Approved COMMENTS: ❑ Approval of a Portion ❑ Denied AAJI S ✓/ /--I?e v cr "gnature- • my Bo:• 'ember Date County Clerk:A legible copy of this form showing the final decision of the County Board of Equalization must be delivered electronically to the Nebraska Department of Revenue within seven days after the Board's decision. Nebraska Department of Revenue,Property Assessment Division Authorized by Neb.Rev.Stet.§¢77-202.01 and 77-202.04 96-135-1999 Rev.1-2014 Supersedes 96-135.1999 Rev.7-2012