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NEBRASKA- Application for Exemption FORM <br /> Good:ifs.Great Service. from Motor Vehicle Taxes by Qualifying Nonprofit Organizations <br /> -To be filed with your county Measure. 457 <br /> la NWT OF MONS •Reed instructions on reverse side. <br /> Name of Organization Type of Ownership <br /> GOOD SAMARITAN SOCIETY-HASTINGS HOME HEALTH ®Nonprofit Corporation ❑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 Zip Code Email Address <br /> GRAND ISLAND NE 68803 CNUSS @GOOD-SAM.COM <br /> identify Officers,Directors,or Partners of the Nonprofit Organization <br /> TWO Name,Address,City,State,Zip Code <br /> DIRECTOR LIZA NELSON,3415 W STATE ST STE 8,GRAND ISLAND,NE 68803 <br /> • <br /> Description of the Motor Vehicles <br /> •Attach an additional sheet,H necessary. <br /> Motor Vehicle Make Model Year g Registration Date a <br /> odyType Vehicle ID Number Date of Acquisition, <br /> if Nally Purdased <br /> CHEVROLET 2013 IMPALA LS 261WE5E38D1111489 <br /> Exempt Uses of Motor Vehicle: Am the motor vehicles used exclusively <br /> Agricultural and Horticultural Society 0 EdEducational g Religious 0 charitable ❑cemetery as indicated? <br /> Give detailed description of use including an explanation if multiple use classifications exist is]YES ONO <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 percentage of exempt use: <br /> U ' of law,I that I have examined this exenptionappication and,to the best of my gmwledge and beWf.It is correct and complete. <br /> sign I also an duly Ills exemption application. <br /> C e (l dRaPr 12-47-18 here Sgnaare <br /> Date <br /> For County Treasurer Recommendation <br /> approval s- C AL SW n'I�7Q0, <br /> _'� a ..e.5 1 r q,. <br /> ❑Disapproval " k '4*' It 3mr <br /> . <br /> i • /J �1 AL(t/UQJl1c ) �-2 l r2 <br /> I DEC 7 :3 n of County Trees. r a <br /> I For County Board of Equalization Use Only <br /> ( t Approval p imenis: <br /> 0 Disapproval <br /> 2 <br /> =ti' _-1_vs e 7) / -�' !Ar <br /> Meant Palmtop*of Revenue • Authorized by Neb.Rev.SWAP n-2MryXciand(N.and SO ties,and 663.189 <br /> 96-253-2006 Rev.r-2015 Supersedes 96453-20N Rev.3-2011 <br /> Please retain a copy for your records. <br />