Laserfiche WebLink
—_--- Application for Exemption R01 ( 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 /> GOOD SAMARITAN SOCIETY-WOOD RIVER ®Nonprofit <br /> Street or Other Mailing Address County Corporation <br /> 1401 EAST ST HALL ❑Other(specify)• <br /> City State 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 /> Please see attached. . . <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 I Vehicle ID Number Date of Acquisition, <br /> if Newly Purchased <br /> GMC 1991 ' Sierra IGTEK14KXME516506 <br /> Ford 2007 • Freestar 2FMZA52247BA02760 <br /> Ford • nyj 2011 . Cutaway 1FDFE4FS5BDB22694 <br /> Dodge-Braun 2014 • Wagon 2C7WDGBGOER220305 <br /> I <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑AgriculturaVHorticulturel ❑Educational Di Religious ❑Charitable El Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: f YES ❑NO <br /> The general use of vehicles is to _transport residents to If No,give percentage of exempt use: <br /> medical appointments, to and from hospital stays and <br /> recreational trips such as State Fair and parks. <br /> Freestar is for staff to go for meetings, staff education and <br /> the Sierra is for maintenance department hauling, etc. <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 /> here Authorized .L,- -- al$-S-Yi 3-as i`l- Title Da e <br /> FOR COUNTY TREASURER RECOMMENDATION I <br /> 9PROVAL RECEIVED COMMENTS: ' "`t� "7--4' -2` • <br /> -Tflfg4G <br /> ❑DISAPPROVAL <br /> g <br /> IV V� A <br /> ii-e to /47 <br /> ✓! f,,,---,-:5 ..� <br /> /Signature of County Treasurer Date <br /> HALL COUNTY FOR COLNTY BOARD OF EQUALIZATION USE ONLY <br /> TRCAGURERC am= <br /> GRAND ISLAND,NEBRASKA <br /> 54APPROVAL COMMENTS: <br /> ❑DISAPPROVAL t ", ' <br /> Au'.rized Sian- ure ate <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§T7-202(1)(c)and(d),and 60-3,165,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 />