Laserfiche WebLink
.� 0 -617 <br /> isifi�WDepartmentof Application for Exemption <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations FORM <br /> PPOPEgTY gE5E55MENi •To be filed with your county treasurer. �a 4 57 <br /> Applicant's Name •Read Instructions on reverse side. <br /> EVANGELICAL LUTHERAND GOOD SAMARITAN SOCIETY-WOOD RIVER Type of Ownership <br /> Street or Other Mailing Address <br /> 1401 EAST ST County Nonprofit <br /> Corporation <br /> City HALL <br /> WOOD RIVER State Zip Code Slate Where Incorporated ❑Oth er(specify): <br /> NE 68883 NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> Tale rllwAwll�� <br /> Please see attached. <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> •Attach an additional sheet,It necessary. <br /> Motor Vehicle Make Model Year Registration Date or <br />• <br /> odyTYpe Vehicle ID Number . Date of Acquisition,Purchased <br /> FORD FUSION SE 2015 If Newl- <br /> 4 DOOR SEDAN 3FA6POH75FR238934 <br /> Exempt Uses of Motor Vehicle: <br /> ❑Agricultural/Horticultural ❑Educational fig Religious Are the actor vehicles used exclusively <br /> ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,Including an explanation it multiple use classifications exist: <br /> EYES I/ NO <br /> Used for travel to home office in Sioux Falls, SD, traveling to If No,give percentage of exempt use: <br /> GSS campuses to work with employees on corporate compliance 80 <br /> issues, fair housing (federal) and state landlord/tenant laws % <br /> in addition to company policy & procedure and survey readiness <br /> checks. <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 duty 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 /> sig .t <br /> here ►A Zed Bl D <br /> Tille , Date <br /> pp� FOR COUNTY TREASURER RECOMMENDATION °� <br /> PPROVAL RECEDE_OMME5 TS: •.1,a-"�t� �9�• 've`/7' — 9' <br /> ❑DISAPPROVAL Mau") <br /> / <br /> Signature o Co ty Treasurer Date /v <br /> HALL • ` - COU BOARD OF EQUALIZATION USE ONLY Date <br /> GRAND ISLAND, NEBRASKA <br /> ❑APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> �� i"�' - <br /> ie.�� , , _..r i/a—/7 <br /> uthor;zedS;gnatu <br /> Date <br /> Nebraska Department or Revenue <br /> 96253-2005 Rev.82011 Supersedes 96253-2006 Rev.5-2009 Auihodzetl by Neb.Rev.Sta1. T7-202(1)(c)antl tl,0-M�' <br /> §§ I) 3185,and 60.3,189 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />