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X017 Application for Exemption FORM Nebraska Department of REVENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations 457 •Te be filed with your county treasurer. •Read instructions on reverse side. Applicants Name Type of Ownership GOOD SAMARITAN SOCIETY-WOOD RIVER Nonprofit Street or Other Mailing Address County Corporation 1401 EAST ST HALL ❑Other(specify): City State Lp Code State Where Incorporated WOOD RIVER NE 68883 NE IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION Title Name,Address,City,State,Zip Code Please see attached. . , DESCRIPTION OFTHE MOTOR VEHICLES •Attach an additional sheet,If necessary. Registration Date or Motor Vehicle Make I Model Year I Bodyrype Vehicle ID Number Date of Acquisition, If Newly Purchased GMC 1991 SIERRA 1GTEK14KXME516506 FORD 2007 FREESTAR 2FMZA52247BA02760 FORD 2011 CUTAWAY(BUS) 1FDFE4FS5BDB22694 DODGE-BRAUN 2014 WAGON 2C7WDGBGOER220305 Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively ❑Agricultural/Horticultural ❑Educational ®Religious ❑Charitable ❑Cemetery as indicated? Give detailed description of use,including an explanation if multiple use classifications exist: ®YES ❑NO The general use of vehicles is to transport residents to If No,give percentage of exempt use: medical appointments, to and from hospital stays and recreational trips such as State Fair and parks. Freestar is for staff to go for meetings, staff education and the Sierra is for maintenance department, hauling, etc. Under penalties of law,I declare that I have examined this applicaton and that it is,to the best of my knowledge and belief,true,complete,and correct.I also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-listed property does not discriminate in membership or employment based on race,color,or national origin. Sign QED �. &.,36inu)cs - -a /a,544 here 11 Authorized Sig Tale Date FOR COUNTY TREASURER,RECOMMENDATION �J APPROVAL jr" .wt:,'S:.. i' /62-2-4--) ,del S_ 77 0=n Q ❑DISAPPROVrL RECEIVED DEC 8 2016 /41-`P� Signature Date FOR COUNTY BOARD OF EQUALIZATION USE ONLY HALL COUNT, 'TREASURERS OF 9 APPROVAL GRAND ISLAND,NE B F (MEN-S: ❑DISAPPROVAL i r �v_� S /-/a-/7 ed S gnature ' Date Nebraska Department of Revenue Authorized by Neb.Rev.Stab§§77-202(1)(c)and(d),and 60.3.185.and 00-3,189 96-253-2036 Rev.8-2011 Supersedes 96-253-2006 Rev.5-2009 PLEASE RETAIN A COPY FOR YOUR RECORDS.