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File with Your County Exemption Application FORM <br /> Assessor on or For a Qualifying For-Profit Nursing Facility,Skilled Nursing Facility,or <br /> Before December 31[ Assisted-Living Facility 451 NF <br /> 4 Annuat Piing.Required _ —_ <br /> Name of Owner "County Name Tax Year <br /> EVI Grand Island "County <br /> 2025 <br /> Name of Business If Different than Owner <br /> Edgewood Grand Island <br /> Street or Other Mailing Address of Applicant 'City Slats Zip Code <br /> PO Box 13238 Grand Forks ND 58208 <br /> Contact Name 1 Email Address Phone Number Parcel Number <br /> Kelly Doda I kelly.doda@edgewoodvista.com r701-757-5406 0400107074 <br /> Legal Description of Real Property <br /> Warren Third Sub LT2 214 Piper St 0-11-9 <br /> What type of for-profit facilityis the exemption beingapplied?(check all that apply) a-'Ii.0 <br /> P PP For more information on r: <br /> ❑Nursing Facility ❑Skilled Nursing Facility Assisted-Living Facility permissive exemptions, h • <br /> please scan the QR code. 5I., <br /> 6.''ot 0. <br /> Does this facility accept Medicaid benetlls? C Yes ❑No <br /> If yes,complete the information below for the most recent three-year period from date the form is completed: <br /> The exemption percentage for each year in the most recent three-year period is equal to a facitty's number of occupied Medicaid beds for a given year divide by the facility's total number <br /> of occupied bed for that year.The exemption percentage for each year is added together and divided by three to calculate the average percentage of occupied Medicaid beds over the <br /> most recent three year period.This number Is the final exemption percentage that will be multiplied by the facility's property taxes to determine the facility's exemption amount.Please see <br /> specific instructions on reverse side for each column below. <br /> 1 i 2 3 4 --- <br /> The three most recent Total number of Total number of 1 Percentage of occupied <br /> years: occupied beds for year occupied Medicaid € Medicaid Beds: <br /> specified in Column(1) Beds for Year 1 Column(3)divided by Column(2) <br /> Year 1:2023 5.53 j .0 0 <br /> Year 2:2324 9.45 0 I 0 _ <br /> 4.921 .33 6.78% "c'E,---.i...:;,,,,i tr 7., <br /> Year 3:2D2_5 I <br /> 5 5a 5b <br /> Calculate the three year Sum of three year Average Occupied r '' 1 <br /> average percentage of Percentages from Medicaid Beds <br /> occupied Medicaid beds I Column(4) Percentage Column <br /> for exempt purposes (5a)divided by 3 :,e;L! ,. _ <br /> 6.78 2.26 <br /> Under penaltie/ law,l are I)saye examined this exemption application and,to the best of my knowledge and belief,it is correct and complete. <br /> I also declare {am u lb sign this exemption application. <br /> sign -, r' f Regional Controller 12/31/25 <br /> 9 1 j <br /> here r Authorized irgna e\;- W \ Title Date <br /> Retain a copy for your records. <br /> I ,.t For County A;cis is ReC ^mendEt'C,^. .__.. <br /> ❑ 'Approval fqr '' COMMENTS: <br /> ❑ Denied f" <br /> 1 Signature of County Assessor Date <br /> _For County Board of Equalization Use Only j <br /> Approved for % If the County Board's determination is different from the County Assessor's recommendation,an explanation is required. <br /> ❑ Denied _ _ <br /> Si. :lure of County:.endue ter 4z1.4-t-as <br /> County Clerk:A legible copy of this for showing the final decision of the County Board of Equalization <br /> must be delivered electronically to the Nebrd ka Department of Revenue within seven days after the Board's decision. <br /> Nebraska Department of Revenue,Property Assessment Division Authorized by Nab.Rev.Stet.f T/-202 <br /> 96-347-2024 Rev.12-2024 <br /> 3 <br /> i <br />