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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 N F <br /> Annual Filing Required <br /> Name of Owner County Name Tax Year <br /> Arbor-Fin Investment, LLC Hall County 2025 <br /> Name of Business if Different than Owner <br /> Broadwell Propco LLC <br /> Street or Other Mailing Address of Applicant City State Zip Code <br /> 265 E MERRICK RD STE 205 VALLEY STREAM NY 11580-6004 <br /> Contact Name Email Address Phone Number Parcel Number <br /> Michael Kramer mkramer@asllc.org 1-516-303-4889 400136538 <br /> Legal Description of Real Property <br /> GOLDEN AGE SECOND SUB PT VAC CAREY ST & PT LT 1 S-T-R: 0-11-9 <br /> What type of for-profit facilely is the exemption being applied?(check all that apply) o..•;+:au <br /> For more information on i9: <br /> ❑Nursing Facility Q Skilled Nursing Facility ❑Assisted-Living Facility permissive exemptions, , { <br /> please scan the OR code. O ? . <br /> Does this facility accept Medicaid benefits? IN 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 3 14,099 10,114 71.7% <br /> Year 2:202 4 15,504 10,768 69.5% <br /> Year 3:202 5 20,148 14,640 72.7% <br /> 5 5a 5b <br /> Calculate the three year Sum of three year Average Occupied <br /> average percentage of Percentages from Medicaid Beds <br /> occupied Medicaid beds Column(4) Percentage Column(5a) <br /> for exempt purposes divided by Column(3) <br /> 213.9% 71.3% <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 /> I also declare tht l am duly authorized to sign this exemption application. <br /> sign ,._g Accountant 12/30/2025 <br /> here Au Ql/b _. <br /> rized Signature Title Date <br /> Retain a copy for your records. <br /> For County Assessor's Recommendation 1 <br /> ❑ Approval for '7 7' % COMMENTS: <br /> ❑ Denied <br /> ' Signature of County Assessor Date <br /> For County Board of Equalization Use Only <br /> Lfa HPproved for_ % If the County Board's determination is different from the County Assessor's recommendation,an explanation is required. <br /> ❑ Denied <br /> 3 <br /> ' Sig lure oT'County)B rd Member Da e <br /> liza <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 Nebras a Department of Revenue within seven days after the Board's decision. <br /> Nebraska Department of Revenue,Property Assessment Division Authorized by Neb.Rev.Slat §§77-202 <br /> 96-347-2024 Rev.12-2024 <br />