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File with Exemption Application FORM Your County for Tax Exemption on Real and Personal Property by Qualifying Organizations 451 Assessor Read instructions on reverse side. Failure to properly complete or timely file this application will result in a denial of the exemption. Name of Organization County Name 1 Tax Year Heartland Health Center, Inc Hall 2018 Name of Owner of Property State Where Incorporated Northwest Crossings, LLC Nebraska Street or Other Mailing Address of Applicant Total Actual Value of Real and Personal Property Parcel ID Number 3307, 3315,3327 West Capital Avenue $ City State Zip Code Contact Name Phone Number Grand Island NE 68803 Kari Wilcox 308-382-4297 x512 Type of Ownership ❑Agricultural and Horticultural Society ❑Educational Organization ❑Religious Organization E Charitable Organization ['Cemetery Organization Name Title of parts Address,City,State,Zip Code or Directors,or Partners Teresa Anderson President 1137 South Locust Street, Grand Island, NE 68801 Deb Ross Vice President 6485 South Baltimore, Hastings, NE 68901 • David Faimon Treasurer 105 North Wheeler Ave, Grand Island, NE 68801 Legal description of real property and general description of all depreciable tangible personal property,except licensed motor vehicles: Medical and Dental Equipment for agency use. . Please see attached listing Property described above is used in the following exempt category(please mark the applicable boxes): ❑Agricultural and liorticutturat Society ❑ Educational ❑ Religious E Charitable ❑ Cemetery Give a detailed description of the use of the property: Heartland Health Center is a Federally Qualified Community Health Center that offers medical,dental and behavioral health services. Our equipment is used to provide care for our patients. All organizations,except for an Agricultural and Horticultural Society,must complete the following questions. Is all of the property used exclusively as described above? E 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 fd NO Is a portion of the property used for the sale of alcoholic beverages? ❑YES ENO 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 E NO Under penalties of law,I declare that I have examined this exemption application and,to the best of my knowledge and belief,it is correct and complete.I al:•d- lare tha ‘1,4 ly aub,rized to sign this exemption application. sign I l . . .. _� Ftnnn6& bicectnr «-1\3 11-7 here Authorized Si n:ure Title Date Retain a copy for your records. For County AsseBSiecprorrle4 on X\ • f IJU�/�) Approval COMMENTS: ❑ Approval of a Portion ❑ Denial ll��7►�- 11� 0111&111 ignature•[rT. ty • sor •Cte l For County Board of Equalization 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. gApproved COMMENTS: Approval of a Portion ' p — :KAI❑ Denied � / .�/gnaturey •unty Board Mem• ` Date D County Clerk:A legible copy of this form showing the final decision of the County Board of Equal brr po 9n must be delivered electronically to the Nebraska Department of Revenue within seven days after the Board's d8ccitskUll Nebraska Department of Revenue,Popery Assessment OMaion Authoezed kAt.(tey$ip`'1§7-202.01 and 7704 96135-1999 Rev.1-2014 Supersedes 96135-1999 Rev.7-2012 �/ll D'�I GRAND/SLgND, UOESR