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e <br /> 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 N F <br /> Annual Filing Required <br /> Name of Owner County Name Tax Year <br /> Emerald Lakeview Realty, LLC Hall County 2026 <br /> Name of Business if Different than Owner <br /> Emerald Lakeview Realty, LLC <br /> Street or Other Mailing Address of Applicant City State Zip Code <br /> 945 N Central Ave Woodmere NY 11598 <br /> Contact Name Email Address Phone Number Parcel Number <br /> Chaim Sprung csprung@emeraldhcm.com 516-426-6744 0400076837 <br /> Legal Description of Real Property <br /> Phillips Sub LTS 1-2-3-4-5-6-7. S-T-R 0-11-9. 1405 W HWY 34 Grand Island NE 68801. <br /> What type of for-profit facility is the exemption being applied?(check all that apply) For more information on 0r,+'ip <br /> ❑Nursing Facility Q Skilled Nursing Facility ❑Assisted-Living Facility permissive exemptions, <br /> r== <br /> lease scan the QR code. • A{ <br /> Does this facility accept Medicaid benefits? ©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 facility'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 2 3 4 <br /> The three most recent Total number of Total number of Percentage of occupied <br /> years: occupied beds for year occupied Medicaid Medicaid Beds: <br /> specified in Column(1) Beds for Year Column(3)divided by Column(2) <br /> Year 1:202 5 26,173 19,810 76% <br /> Year 2:202 4 24,980 18,641 75% <br /> Year 3:202 3 24,421 18,736 77% <br /> 5 5a 5b <br /> Calculate the three year Sum of three year Average Occupied REC,-._;VElm' <br /> average percentage of Percentages from Medicaid Beds <br /> occupied Medicaid beds Column(4) Percentage Column <br /> for exempt purposes (5a)divided by 3 N 0 5 ^r,+1 <br /> 227% 76% <br /> s <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 lets.-,' =:S J . <br /> I also declare that 1 am duly authorized to sign this exemption application. GRAND- 5: ' <br /> sign i. i Nt.� Accounts Payable 12/31/2025 <br /> here Authorized S nature Title Date <br /> Retain a copy for your records. <br /> For County Assessor's Recommendation 1 <br /> ❑ Approval for f t - % COMMENTS: <br /> ❑ Denied <br /> (' Signature of County Assessor Date <br /> For County Board of Equalization Use Only <br /> Approved for % If the County Board's determination is different from the County Assessor's recommendation,an explanation is required. <br /> ❑ Denied <br /> 1 <br /> Sig, lure f Co my and l ember Date <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 Nebraska Department of Revenue within seven days after the Board's decision. <br /> Nebraska Department of Revenue,Properly Assessment Division Authorized by Neb.Rev.Stat.§§77-202 <br /> 96-347-2024 Rev.12-2024 <br />