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N�^ &l,A Application for Exemption FORM <br /> � '� ora �- <br /> Good Life.Greatservice. from Motor Vehicle Taxes by Qualifying Nonprofit Organizations 457 <br /> -To be filed with your county treasurer. <br /> .o•.T.aT a•arvowe •Read Insuuclions on reverse side. <br /> Name of Organization Type of Ownership <br /> GSS HASTINGS VILLAGE HOME HEALTH ®NoriprotdCorporation ❑Omer(specify): <br /> Name of Owner of Property County Name Stale Where Incorporated <br /> HALL NE <br /> Street or Other Mailing Address Contact Name Phone Number <br /> 3415 W STATE ST STE B CRYSTAL NUSS 308-382-4054 <br /> Cray State rip Code Email Address <br /> GRAND ISLAND NE 68803 CNUSS@GOOD-SAM.COM <br /> Identify Officers,Directors,or Partners of the Nonprofit Organization <br /> Title Name,Address,City,State,Z•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,N necessary. <br /> Motor Vehkle Mahe Model Year Bodylype Vehicle ID Number Registration <br /> ate of Acquisition, <br /> it Newly Purchased <br /> CHEVROLET 2013 IMPALA LT 2G1WB5E34D1111853 <br /> CHEVROLET 2011 IMPALA LT 2GTWG5EK4131235613 <br /> Exempt Uses of Motor Wide: Are the motor vehicles used emdusively <br /> ❑Agricultural and Horticultural Society 0 Educational Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detailed descdplton of use,inducing an explanation if nlWtple use classifications exist IN YES ❑NO <br /> NURSES AND CNA'S DRIVE TO THE HOME OF OUR CLIENTS TO PROVIDE NURSING H No,give CARE AND OTHER ASSISTANCE AS DEEMED IN THEIR CARE PLAN. g percentage of exempt use: <br /> x <br /> of law,l then have eramtoed this exemption application and,to the best of my kroedelge end belief,h is correct and complete. <br /> I aleo I em duly to sign mie exerrplion applca ion. <br /> sign • Z1° klana ttsi s' <br /> here , &Odra Title Dale <br /> For County Treasurer Recommendation <br /> pproval r— - ------------commgnts: fiarilft ALsrs#77 aoa. <br /> ❑Disapproval <br /> c ib ^D ? <br /> Signature of County Tree9u <br /> For County Board of Equalization Use Only <br /> Cnmmi3nts_ <br /> ❑Disapproval <br /> ►� – l/ 64-1—t-, --C lV_ c li. <br /> •4.rzed Signature Date/ <br /> Nabtlu Department al Revenue MMOrized by Nee• :,■ ':Tx ,.. )o end m.and,, 1- ,and 603,189 <br /> 96-253-2006 Rev.7-2018 Supenad.96-263-2006 Rev.8-2011 <br /> Please retain a copy for your records. <br />