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03/17/2017 14:21 FAX 3083855061 • Hall County Treasurer 1a0001/0001 <br /> t <br /> "e,1. <I I Application for Exemption FORM <br /> N from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> •To be food Mtn your county treasurer, • <br /> •Raid Mslmobone on MOM side, <br /> Apptoenfe Nana type ol Ownership <br /> CHI Health-St Francis Hospital - g NonproM <br /> Street oi0ter Means Andreae • • County Corporation <br /> 2820 W Fatdley Ave Hall Q OMR(spongy): • <br /> City_ Stall 2tp Code Slate Whirs Ineovoroled <br /> Grand Island NE 88803 Nebraska <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Tine Name,Addnee,City,elate,Zip Code <br /> Director Supply Chats wit Henley,12000 West Dodge Road Omaha,NE 00154 <br /> DESCRIPTION OFTHE MOTOR VEHICLES <br /> . •Attaoh an additional sheet,N Beoaesary. <br /> MotorVehMle Make Model Year Bed Ra Date ItttAcc Delon, <br /> Body VahldeID Number If Newly Purchased <br /> Nissan. 2017 Sentra•S(CVT)4dr Sedan 3NIAB7AP3HLE3660e ,J—. O—/7 <br /> Exempt Wes of Motory.Nde: Amite motorvehloan used exclusively <br /> ❑Agdwlturas/lmballerm 0 Eduoanaw f t Refgaus to Charitable 0 cemetery tie Indicated? <br /> Give Misled description of use,Indudnp an explanation If muspie use dessmcations mdse OYES 0 N <br /> Vehicle will be used to provide services within the organization. Supporting operations of <br /> $t. Francis Hospital in the daily functions for nurses and patients. If No,give percentage ol exempt arse: <br /> • <br /> Under pukka ol law,I dedere that l have examined Ihk epprbadon and that R 11,10 the beet of my letowledge and beset kue,complete,and correct! <br /> aim dedarebail am duly authorized lesion thlsexemplbn eppeoadon,aM SWIM organization owning be ebow-IIsted property doss net dispMerete <br /> In membership employment based enlace,cobs arnasond origin. <br /> Sign Director Supply Chain 3//? �17 <br /> here ■"mired. Tine Date <br /> FOR COUNTY TREASURER RECOMMENDAT ION • <br /> alrWPROVA. RECEIVEDOOMME rm. t AA2-A-- 4A9C--4.• A1-77—<2042 • <br /> Q DISAPPROVAL <br /> MAR 1 7 2017 44 3-a3--i7* <br /> SSMean Treeferer Oak <br /> HALL,COUNTY FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> GRAND ISLAND.NEBRASKA <br /> trik APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> CIIIIWSOW17-at toe at 4,5110. It, c,109 <br /> -- •teed nature W •?P <br /> r <br /> Nebnku DnwoneMd Remus AvnwdtedbyNm.No:anLt4M- 2f Igo)end Mad MAIN,end 6041U <br /> ae@S5QWf Rev.eaell&reds,96t63.00a Rev.6100 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS. <br />