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Exemption Application <br /> Ale with Your County 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 l County Name Tax Year <br /> RIVERSIDE LODGE RETIREMENT COMMUNITY LLC HALL COUNTY 2026 <br /> Name of Business if Different than Owner <br /> Street or Other Mailing Address of Applicant I City State Zip Code <br /> 404 WOODLAND DR 'GRAND ISLAND NE 68801 <br /> Contact Name ±Email Address Phone Number Parcel Number <br /> BRIAN STUHR BSTUHR@VHSMAIL.COM 402-895-3932 1400295237 <br /> Legal Description of Real Property <br /> MISCELLANEOUS TRACTS 28-11-9 PT LT 1 ISL & PT SE 1/4 13.74 AC 404 WOODLAND DRIVE, GRAND ISLAND, NE <br /> What type of for-profit facility is the exemption being applied?(check all that apply) For more information on m. If A <br /> . Nursing Facility G Skilled Nursing Facility 0 Assisted-Living Facility permissive exemptions, "�f` "^" <br /> please scan the OR code. • >, 44-' <br /> Does this facility accept Medicaid benefits? I Yes L 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 he 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 /> f <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 1:2025 27375 4364 16% <br /> Year 2:2024 27375 5058 18% <br /> Year 3:2023 27375 6263 23% ¢ <br /> l R'ECEt`dF.; L;. <br /> 5 5a 5b <br /> Calculate the three year Sum of three year Average Occupied 6 <br /> average percentage of Percentages from Medicaid Beds DEC 2 2025 <br /> occupied Medicaid beds Column(4) Percentage Column <br /> for exempt purposes (5a)divided by 3 HALL COUNTY ASSESS0 <br /> 57 19% GRAND ISLAND; NEBR SK.A <br /> Under penalties of law.I declare at I v xamined this exemption application and,to the best of my knowledge and belief.it is correct and complete. <br /> I also declar am duly a r' ed sign this exemption application. <br /> sign � <br /> CFO 12-23-2025 <br /> lew —. <br /> Retain a copy for your records. <br /> .` For County Assessor's Recommendation <br /> ❑ Approval for o COMMENTS: <br /> Li Denied <br /> ' Signature of County Assessor Date <br /> I For County Board of Equalization Use Only <br /> ir;iipproved for °re If the County Board's determination is different from the County Assessor's recommendation,en explanation is required. <br /> Denied t <br /> d <br /> : tf,r(/'1 / , / ,er.,"///I 3 12.,(49/2_Co <br /> Si rrptuie of County and Member Date <br /> County Clerk:A legible copy of this form 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 /> NehrasKa Department at Revenue Proper:'A„essmeni Division Authorized by Neb.Rev Stet §77-202 <br /> 96-347-2024 Rev 12-2024 <br />