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tr110312518 11:30 3083824033 r P.0011002 <br /> t1r Z <br /> -- Application for Exemption FORM <br /> REVENREENUE from Motor VehicleTaxes by Qualifying Nonprofit Organizations <br /> UE 'To be died with your county sheerer. 457 <br /> •Read Mstuotlons en reverse side. <br /> Assawnaa Name hype of Ownership <br /> Evangelical Lutheran GSS Hastings Village Home Health ®Nonprofit <br /> Street or Other Maring Address County Corporation <br /> 3415 W State St,Ste B . Hall D Other(specify): <br /> Cie State Zip Code State Where Incorporated <br /> Grand Island NE 68803 NE <br /> IDENTIFY OFFICER$,DIRECTonS,OR PARTNERS OFTHE NONPROFIT ORGANIZATION <br /> Tea None,Address,CRY.State,Zip Code <br /> Director Ltza Nelson,3415 W State 81,-Ste B,Grand Island,NE 68803 <br /> DESCRIPTION OFTHE•MOTOR VEHICLES <br /> *Attach an additional sheet,N necessary. <br /> Dateor <br /> Motor Vehicle Make Model That BOOyType VMlde IC NlStlber of Aequietaon <br /> _ N Newly Purchased <br /> FORD 2012 FUSHIQN SE.. 3FAHPOHAOCR355742 1/2017 <br /> FORD 2012 FUSNION SE• ' _ SFAFIPOMA5CRS55?S6 1/2017 <br /> FORD 2012 FUSHION SE 3FANPOHA1CR345QS1 12017 <br /> CHEVROLET 2011 IMPALA 201WASEKSB1164007 1/2017 <br /> CHEVROLET 2013 IMPALA ' 201WR5E3401111853 12017 <br /> Exempt Uses of MotorWHole: R� ' Are the MOtoritveMdee used exclusively <br /> 0 Agriculw,etilortkulplral ❑Edueetionel al Religious ®Ohattable ❑Cemetery as indtatellt <br /> Give detailed description of use,Inducting en explanation II m*tile use classifications exist • OYES ❑NO <br /> Nurses and nursing aides use vehicles to drive to the home of dients to provide care. if No,give percentage of exempt uset <br /> 15 <br /> • <br /> Under penalties Of Iae I declare that I have examined dus.appe°eaon and Mat It Is,to me Best of my knowledge and beef,tme,complete,and correct.I <br /> abo declare tat I am duty autlgdadto flan tie exemption a ppiG7tCn,end Suite organization wining the.above-lieled properydoes not discriminate <br /> In membership or amgbydant based MI red,color,or motional origin . <br /> sign `LI. Office Manager 1/3/2018 <br /> her ared ^ rile Date <br /> j `FOR COUNTYTREASURERRECOMMENDATION 1 <br /> APPROVAL RECEIVE c r. cony`"`"";T — �2p� /i S.-5. v'J'"9D0�� <br /> 0 DI$APPROV' <br /> NOV • <br /> 2 7 2017 • a— a /c —aB=i7 <br /> agreatre v <br /> (>a e <br /> Mow - FOR CO • BOARD OF EQUALIZATION USE ONLY . - <br /> TREASURERS OFFICE <br /> ROYAL GRAND ISLAND NEBRAGIDM. a •CI DISAPPROVAL • . <br /> / 7-/ S' <br /> . ...Signore Date <br /> Nebrees Department at Revenue Astor zedto Neb.R•;Sot if 7f403(1)(*1 and(ol,end504te5,end W$,16O <br /> $42534000 Rev.$4011 browsed.*55-804QOf rev.Moe • <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS, <br />