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File with Exemption Application FORM Your County for Tax Exemption on Real and Personal Property by Qualifying Organizations Assessor Reed instructions on averse side. 451 I Failure to properly complete or timely file this application will result in a denial of the exemption. Name of Organization County Name Tax Year CHI Health Hall 2016 Name of Owner of Property Stale Where Incorporated Saint Francis Medical Center Inc., do Property Management Nebraska Street or Other Mailing Address of Applicant Total Actual Value of Real and Personal Property Parcel ID Number 12809 West Dodge Road $ 400036177 City Stale Zip Code Contact Name Phone Number Omaha NE 68154 Don Mandel Type of Ownership 402.343.4431 0 Agricultural and Horticultural Society ❑Educational Organization ❑Religious Organization Charitable Organization ❑Cemetery Organization Name Title of Officers, Directors,or Partners Address,City,State,Zip Code Cliff Robertson CEO&Senior VP 12809 West Dodge Road,Omaha, NE 68154 Jeanette Woitalewicz CFO 12809 West Dodge Road, Omaha, NE 68154 Richard Herink Board Chair 6600 South 27th Street, Lincoln, NE 68512 Legal description of real property and general description of all depreciable tangible personal property,except licensed motor vehicles: Property Address: 705 ORLEANS DR Legal Address: COLONIAL ESTATES SECOND SUB TO THE CITY OF GRAND ISLAND LTS 2&3 BLK 3 �''` Property described above is used M the following exempt category(please mark the applicable boxes): R E . ❑Agricultural and Horticultural Society ❑ Educational ❑ Religious ®Charitable ❑ Cemetery V ��, VVV Give a detailed description of the use of the property: JUN 2 9 2016 Location is occupied by CHI Health an non-profit health care organization providing medical ser�iig ir�i chaptable-rftre for those without funds for payment. tiNLL H�1at55U GRAND ISLAND,NEBRASKA All organizations,except for an Agricultural and Honicuiural Society,must complete the following questions. Is all of the property used exclusively as described above? g: 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 property 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 ®NO _ Under nettles of law,I dec that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and complete. N declare I et I �//uty aut d to this exemption application. here ' Mt Dried Signature e Director of Real Estate 4,//i- Retain a copy for your records. i For County Assessor's Recommendation it Appnwal COMMENTS: _f g n k T . aea- 0 Apes:Aral of a Portion ❑ Denial C.- 3t-6c, Signature of Cott season pate For County Board of ualization 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 afar i , ❑ Denied /L/� �� � /j e: e, le Of ri '41!-1T , 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.Re..Stet.§§77-202.01 end 77-202.04 96-135-1999 Rm.1-2014 eteersedss 96.135.1999 Reel-2012