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()\ Filewith Statement of Reaffirmation of Tax Exemption FORM our County il ssessor for Use When Applying for Continued Exemption for Qualifying Organizations 451 A Failure to properly complete or timely file this statement will result In a denial of the exemption. Vane of Organization County Name Tax Year CEMENT LODGE 211 AF&AM HALL P018 Name of Owner of Properly State Where Incorporated CEMENT LODGE 211 AF&AM NEBRASKA Street or Other Mailing Address of Applicant Parcel ID Number • 408 W 13TH 400176521 City State Zip Code Contact Name Phone Number WOOD RIVER NE 68883 Type of Ownership ❑Agricultural and Horticultural Society ❑Educational Organization ❑ Religious Organization ®Charitable Organization Legal description of real property and general description of all depreciable tangible personal property,except licensed motor vehicles: • WOOD RIVER VILLAGE N 56'OF W 1/2 LT 11 &N 26'OF S 72'OF LT 11 & N 29'S 73'OF LT 120 BLK 20 (904 MAIN ST) • I hereby state that I am the authorized representative of the organization owning the property described above and that the use of this property has not changed during the previous year. sign ) , . _/l /...`" l�u.,��: //-a5-17 here A h.rizedSgnafu / 1 Title Date Retain a copy for your records. For County Assessor's Use Only �lJ'tt1UrD[(L • • ate calved i'C KY- k e r ignaturb Instructions Who May File.An organization that owns real or tangible personal property,except licensed motor vehicles,and is seeking continuation of a property tax exemption must file this Statement of Reaffirmation of Tax Exemption,Form 45IA,if: 1. The property is owned by and used exclusively for agricultural and horticultural societies;or 2. The property is: a. Owned by educational, religious, or charitable organizations, or any organization for the exclusive benefit of any educational,religious, or charitable; • b. Used exclusively for educational,religious,or charitable; c. Not owned or used for financial gain or profit to either the owner or user; d. Not used for the sale of alcoholic beverages for more than 20 hours per week;AND e. Not owned or used by an organization which discriminates in membership or employment based on race,color, or national origin. An organization must file a Form 451 if new property is acquired or if the property is converted to exempt use.• When And Where To Ale.The Form 451A must be filed on or before December 31 prior to each intervening year,those years not evenly divisible by four,with the county assessor of the county where the property is subject to.tax. Late Filings/Waivers.If an organization fails to file a Form 451A on or before December 31,it may file the Form 451A on or before June 30,with the county assessor,to maintain the tax exempt status of the property. Filing by this date nullifies any previous action by the county board of equalization denying the exempt status. If a late filing is made, the county assessor must assess a penalty against the organization in the amount of 10%of the tax that would have been assessed had the statement not been filed or$100, whichever is less,for each calendar month or fraction thereof for which the filing of the statement missed the December 31 deadline. . The penalty may not be waived. g Specific Instructions.The completed Form 451A must be retained by the county assessor. 2 9 - - Nebraska Department of Revenue.Property Assessment Division Authorized by Neb.Rev.Stet.§77.202.03 96-155-1999 Rev 1-2014 Supersedes 96155-1999 Rev.7-2012