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N_EBRA� S44"1- Application for Exemption FORM <br /> Good Life.Great Service. from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> .o..,,e„•,,,,, •To be riled with your county treasurer. 457 <br /> •Read instructions on memo side. <br /> Name of Organization Type of Ownership <br /> GOOD SAMARITAN SOCIETY VILLAGE HOME HEALTH Ab ®Nonproitcorporaticm ❑other(specify): <br /> Name of Owner of Property County Name State Where Incorporated <br /> HALL NE <br /> Street or Other Malting Address Contact Name Phone Number <br /> 3415 W STATE ST STE B CRYSTAL NUSS 308-382-4054 <br /> City State tip Code Emaa Address <br /> GRAND ISLAND NE 68803 CNUSS@GOODSAM.COM <br /> Identify Officers,Directors,or Partners of the Nonprofit Organization <br /> Tide Name,Address,City,State,Zip 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 Date of Acquisition,Date or <br /> if Newly�rchased <br /> FORD 2009 FOCUS SE 1 FAHP35N59W267445 <br /> Exempt Uses of Motor Vehicle: <br /> exclusively Agricultural and Horticultural Society ❑Education ®iea9i°ua ❑Chitable ❑cemetery as indicated?Give derailed description of use,including an explanation if multiple use classifications sorest ®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. If NO'give oe percentage of exempt use: <br /> _x <br /> U ..-!t�' m I. ,••i ,that I ham examined this exemption application anti,to the best <br /> Sin I aka -N-}} that I am to sign this exemption application. �// car knowledge a d belief.a s correct and complete. <br /> here .` ,l^ — afr __ ___ P! /2---)8 <br /> Tale Dale <br /> For County Treasurer Recommendation <br /> proval Com f <br /> m n : Att na Oa <br /> ❑Disapproval • .. <br /> Q n!. F ) /14 7112 <br /> I _ _ For County Board of Equalization Use Only I <br /> • <br /> itAPp ! - -:tommehis: <br /> _ <br /> ❑Disapproval <br /> A�_./_ _^ -- /� �/ Sf /r <br /> Audp- '•Signature Date <br /> Nebraska eeparenera of aawnue <br /> Authorized Neb.Rev.8M. <br /> 96-25}2006 Rev.7-2016 Supersedes 96-253-2006 Rev.52011 by S4 T" 1111pI+na(d).end a0.1.ta5.end f103.t89 <br /> Please retain a copy for your records. <br /> I <br />