Laserfiche WebLink
File with Your County; Exemption Application or <br /> FORM <br /> Assessor on or For a Qualifying For-Profit Nursing Facility,Skilled Nursing Facility, <br /> Before December 31 I Assisted-Living Facility 451 NF <br /> I Annual Filing Required <br /> Name of Owner County Name Tax Year <br /> Quality Loving Care, LLC Hall 2025 <br /> Named Business if'Different than Owner <br /> Prairie Winds Assisted Living <br /> Street or Other Mailing Address of Applicant City —I Stale Zip Code <br /> 603 W.6th Street Doniphan NE __ 68832 <br /> Contact Name Email Address Phone Number Parcel Number <br /> Amber Wiechman pwadministrator@hamilton.net1402-845-4500 0400384124 <br /> Legal Description of Real Property <br /> Doniphan Village Prairie Winds Third Sub LT 1 <br /> What type of for-profit facility is the exemption being applied?(check all that apply) For more information on CI iri.Q <br /> f. .s i_; <br /> El Nursing Facility ❑Skilled Nursing Facilityl�L?•J Assisted-Living Facility permissive exemptions, Iv#i;' <br /> please scan the OR coda. k.o- <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 toe facility's number of occupied Medicaid beds fore given year divide by the facility's total number <br /> of occupied bed for that year.Ths 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 I 4 <br /> The three most recent Total number of Total number of I Percentage of occupied <br /> years: occupied beds for year occupied Medicaid I Medicaid Beds: <br /> specified In Column(1) Beds for Year Column(3)divided by Column(2) <br /> Year 1:202 5 331 187 56% <br /> Year 2:202 4 326 161 I 49% <br /> Year 3:2022 340 155 l 46% RECEIVED <br /> 5 5a 5b <br /> Calculate the three year Sum of three year Average Occupied <br /> average percentage of Percentages from Medicaid Beds j AN ci 3 L'O Z B <br /> occupied Medicaid beds Column(4) Percentage Column <br /> for exempt purposes (5a)divided by 3 <br /> 151% i i 50% , 1. SSSSRHtLL COL .. A O <br /> GRAND iSJ. . ), \EERA.S:K A <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 /> leis 'e that I am duly authorized to sign this exemption application. <br /> sign , A_A A inistrator 12/31/2025 <br /> here r A rized Signature Title Date <br /> Retain a copy for your records. <br /> —,-- For County Assessor's Recommendation 1 <br /> ❑ Approval for ,_ a` ." 'Y. COMMENTS: <br /> ❑ Denied <br /> ' Sigruuure of County Assessor Date <br /> l_ For County Board of Equalization Use Only <br /> le-Approved for % It the County Board's determination is different from the County Assessor's recommendation,an explanation Is required. <br /> _I <br /> ❑ Denied <br /> . -A <br /> / i' 1 _ <br /> Sign-lure of c.0 coard tern sat- <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 Nebra a Department of Revenue within seven days after the Board's decision. <br /> Nebraska Department of Revenue,Properly Assessment lte,sron authorized by Neb.Rae..Stet §§77-202 <br /> 96-347-2024 Rev 12-2024 <br />