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NEB4ZAS-14.74 Application for Exemption FORM <br /> Good Life.Great Service. from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> •To be filed with your county treasurer. l 457 <br /> ^•°^^"^•"*°^•°°^"• I •Read instructions on reverse side. <br /> I <br /> Name of Organization Type of Ownership <br /> GOOD SAMARITAN SOCIETY WOOD RIVER ®Nonprofit Corporation ❑Other(specify): <br /> Name of Owner of Property County Name State Where Incorporated <br /> HALL NE <br /> Street or Other Mailing Address Contact Name Phone Number <br /> 1401 EAST ST Kassy Shultz 308-583-2214 <br /> City State Zip Code Email Address <br /> WOOD RIVER NE 68883 kshultz @good-sam.com <br /> Identify Officers,Directors,or Partners of the Nonprofit Organization <br /> Title Name,Address,City,State,Zip Code <br /> Please see attached. . . . <br /> Description of the Motor Vehicles <br /> •Attach an additional sheet,if necessary. <br /> Registration Date or <br /> Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> it Newly Purchased _ <br /> GMC 1991 Sierra 1GTEK14KXME516506 _ <br /> FORD 2007 Freestar 2FMZA52247BA02760 <br /> FORD 2011 CUTAWAY (Bus) 1FDFE4FS5BDB22694 _ <br /> DODGE-BRAUN 2014 WAGON 2C7WDGBGOER220305 <br /> Exempt Uses of Motor Vehicle: Are the motor vehicles used exclusively <br /> ❑Agricultural and Horticultural Society 0Educational Religious ❑Charitable 0 Cemetery as indicated? <br /> Give detailed description of use,including an explanation if multiple use classifications exist: IN YES ii NO <br /> • <br /> The general use of vehicles is to transport residents to If No,give percentage of exempt use: <br /> medical appointments, to and from hospital stays and i <br /> recreational trips such as State Fair and parks. <br /> Freestar is for staff to go to meetings, staff education, and <br /> the Sierra is for maintenance department, hauling, etc. <br /> 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. <br /> I also declare that I am duty. horized to sign this exemption application. <br /> a�CAm n1 a- 0- 19, <br /> sign i�.t t+e_ i .. . !.� tnst 1 cif 1 I <br /> here Aut :rind Signature ` • Title Date <br /> TT For County Treasurer Recommendation <br /> k(gprovaI 1e ,R E ; + k5 ��V <br /> u� <br /> aa.8Cit s / <br /> ❑Disapproval <br /> DEC 0 2018 w ►arltt1VI <br /> Signature of County Treasu r Date <br /> For Count Board of Equalization Use Only <br /> HALL t,uuhTTY <br /> ,�-A <br /> TREASURERS OFFICE <br /> p ,Approval GRAND ISLAND,NEUVA.iti. <br /> /❑•Disapproval <br /> AM Gam. cie..--------_. /:)--(-. C- <br /> Auth• ized Signet ' Da• <br /> Nebraska Department of Revenue Authorized by Neb.Rev.Stet_§§77-202(1 Ac)and Id),and 60-3,185.and 60-3,189 <br /> 96-253-2006 Rev.7-2018 Supersedes 96-253-2006 Rev.8-2011 <br /> Please retain a copy for your records. <br />