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Dec. 2. 2015 10:59AM SFMC EXECUTIVE OFFICE No_ 2871P. 2 <br /> nab ewyte% <br /> or <br /> Application for Exemption A 01(c FORM <br /> Department tram Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> tilliOlgt •To botaMwkh your county treasurer. 457 <br /> •Road InMmottono an reverse side, <br /> Appgeann Nome Typed Ownership <br /> SAINT FRANCIS MEDICAL CENTER ®Nonprofit <br /> Sbea ototherllaang Address county Oorpmaton <br /> • <br /> 2620 W FAIDLEY AVE PO BOX 9804 HALL ❑Dews lepedty), <br /> •City Mate aP Code state Where Incorporated <br /> GRAND ISLAND NE 68802 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS DFTHE NONPROFIT ORGANIZATION <br /> Tile Name,Address,Os State,Zip Code <br /> President Dan McE17iigott,PO Box 9804.Grand Island,NE 68802 <br /> CEO-CHI Health . Cliff Robertson.MD.12809 West Dodge Road,Suite 368.Omaha,NE 68154 _ <br /> BoardMembcr Barry Sandstrom,PO Box 1009,Grand Island,NE 68802-1009 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> 'Attach an additional sheet,It noes aty. _ <br /> Brightman Dale or <br /> Motor Welds Make Nadel Yea' Lk*TYPO WNde ID Number Pit. <br /> s Purchased <br /> SEE ATTACHED LIST <br /> ammo tits;tNotorsi S: • - Are the motorvotds$used ende Vet <br /> ❑ ❑Educational N Religious ❑mar/at ❑cemat.ry as ndbaam <br /> Give deleted desuknkn of ew.Including an a®lanatan It aelglpie use dadicatlan adel: (RYES ONO <br /> Transport hospital equipment and patients between buildings. i No. we parwrdaga of atemp use: <br /> Transport cash bags to bank and back. % <br /> Transport patient food and laundry between buildings. <br /> under partials.ot law,I dedare Mail/13W examhed WsappIcMbn and Ilial kIs,lo atebW afmy latdasedge end begot VOL LIMNS and also doelam that I am duty semadzed to sign Ins n esa don app oadoka o.adthatan anina wa <br /> ion owning *bewailed property does Ace discriminate <br /> in awreberaNp oresplcyi nm based on nee,cit.or notional;Agin. <br /> sign �, 4/J4-- V9 '* j 1,sL hi /- 8 <br /> • here y . • <br /> FOR COUNTYTREASURER RECOMMENDATION <br /> MAPPROVAt RECEIVEQOMUENLS: -r /a "-.7 7—ege,,2, <br /> ❑DISAPPROVAL ��SF ° <br /> DEC 2 2015 �� 5 /?—./6 s-, <br /> Slunabaa of C otadyrmaturm Dale <br /> i .� a IAJ-CO DrtTl BOARD OFEGUALQATION USE ONLY <br /> —gyp GRAND ISLAND,UNE <br /> etIPPROVAL COMMENTS: <br /> •••0 DISAPPROVAL <br /> lie <br /> shoal Naas of Memo AvaoMad Iy N•b.hwSed.if 7?-4CW)I4 end(d).end waits,am byes <br /> seessQwa net sobl I atpaaaan inst020011 as 5-2009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />