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NEBRAtsitev I Application for Exemption FORM <br /> Good Life.�reatService. from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> ,,,,,,,,o„•„�•,a •To be filed with your county treasurer. A 57 <br /> •Read inatniWons on reverse side. YJ <br /> Name of Organization Type of Ownership <br /> EVANGELICAL LUTHERAN GSS HASTINGS VILLAGE HOb El Nonprofit Corporation ❑Other(specify): <br /> Name of Owner of Property County Name Stale Where Incorporated <br /> HALL NE <br /> Strait or Other Mating Address Contact Name Phone Number <br /> 3415 W STATE ST STE B CRYSTAL NUSS 308-382-4054 <br /> City State Zip Code Emile Address <br /> GRAND ISLAND NE 68803 CNUSSC+GOODSAM.COM <br /> Identify Officers,Directors,or Partners of the Nonprofit Organization <br /> T'de Name,Address,qty,State,Zp Code <br /> DIRECTOR LIZA NELSON,3415 W STATE ST STE B,GRAND ISLAND,NE 68803 <br /> Description of the Motor Vehicles <br /> •Attach an additional sheet,If necessary. <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number D��OO^�n,of Acquisition, <br /> FORD 2012 FUSHION SE 3FAHPOHAOCR355742 <br /> if Newly Purchased <br /> FORD 2012 FUSHION SE 3FAHPQt4A5CR355736 <br /> FORD 2012 FUSHION SE 3FAHPOHA1CR345091 <br /> CHEVROLET 2011 IMPALA LS 2GIWASEK5S1164097 <br /> Exempt Uses of Motor Vehicle: <br /> El Agricultural and Hortigabrrel Are the motor vehicles used exclusively — <br /> Society ❑Educational i i Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed description of use,alluding an mplanason if multiple use classifications exist ®YES ❑NO <br /> NURSES AND CNA'S DRIVE TO THE HOME OF OUR CLIENTS TO PROVIDE NURSING <br /> CARE AND OTHER ASSISTANCE AS DEEMED IN THEIR CARE PLAN. a No.a e pe cemape of exempt tie: <br /> 1 <br /> Under penalties of ,I declare that I have examined this exemption application and,to the best of my knowledge and beliet it Is correct and complete. <br /> I a that I aulhonzed to sign this exemption application. <br /> sign <br /> here re T /2-6,-Ig <br /> I Pot <br /> County imagine RecommendatiOn <br /> (0ApProyal ` —m • // nl & / SS r . <br /> 2oa <br /> ❑Disapproves <br /> 1. • ". . //®,, <br /> S�'C 1i V' Babs)L a r�1711a <br /> i UCH L- of County r Date <br /> I U C For County Board of Equalization use Only j <br /> Z1 Approval - 'E <br /> ❑Disapproval a <br /> Alen (...- -- 7 ..-1//:;1(.<Sid <br /> i sized Signature Date <br /> i <br /> Nebraska eaoeraaent or Revenue <br /> hewing by Neb.Rev.But.4477-202 m0C)and(d).and Coates.and eoa.les <br /> 96163-22006 new 74018 Stcesedes 96-253.2006 Rev.8-2011 <br /> Please retain a copy for your records. <br />