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File with Your Application for Exemption FORM County Treasurer from Motor Vehicle Taxes by Qualifying Organizations 457 •Read instructions on reverse side. _ Name of Organization Tax Year Value of Motor Vehicles Good So.m(XYi}o.`n SoCVC,' Grand Is1atnc). V 11ojI 2026 in ,000 Name of Owner of Property County Name State Where Incorporated Good SQrnori*cxrn SOcieky Grand Islty,cld Villq 1do.11 NE Street or Other Mailing Address / Contact Name Phone Number LiOnS -c';r r'iirt 5* AniK0. Calk- SO'1 -220-2.2SS / City State Zip Code/ Email Address Cyr an6 \S1ra.nd NE c,8803 _ anika . guS-1-0 rod_Sam.Corn- / Type of Ownership: ❑Agricultural and Horticultural Society ❑ Educational ® Religious ❑ Charitable ❑ Cemetery ❑ For-profit Nursing Facilities Charitable Organizations:Motor Vehicle described above is used in the following exempt category(please mark the applicable boxes): ❑Agricultural and Horticultural Society ❑ Educational ® Religious ❑ Charitable ❑ Cemetery Charitable and For-Profit Organizations,please answer the following: If No,give percentage of exempt use: Are the motor vehicles used exclusively as indicated?(see instructions) X, YES ❑ NO % / For-profit Nursing/Assisting Living Facilities,please select the applicable box: What percentage of occupied beds have been provided to ❑ Nursing Facility ❑Skilled Nursing Facility ❑Assisted-Living Facility medicaid beneficiaries over the most recent three-year period? Name Title of Officers, Address,City,State,Zip Code Directors,or Partners No.*e 5cherno.- C.“) 4go0 v1 5-1-t-h S4 , SiO-tAx FobttS . SD 5.7I0$ :1 0C—l- F 1-v Cr r;,FO Li%oo W 5-1 kh 5+ , SiOA.xX C-p.lIS , SP S-t 1O$ At tn ..- tAtoOLE'rON C,w3 t-t8O0 \-1 Sn +h 5 S i0‘..17s F1:71/4.11 s, Sp Si 103 Description of the Motor Vehicles •Attach an additional sheet,if necessary. Registration Date or Motor Vehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition if Newly Purchased FORD FVStonl 2016 y OQOR SfcOAtt 3FA6p ow)4GR30go22 21 -SAtt-2O2S GoRo F'us1 onl 20 t2 y 000l. seOA,nt 3FAHPOHA0GR3r15-142 4 - FE8 -2O2S C.1.1E-vY IMPALA 2013 Li DOOR SEDA*1 2GIwFSESS011l1469 1I -7.104- 2025 Give a detailed description of the use of the motor vehicle: de ,fop and Veh:G\ S aft u.Std • of SKi\\ed rtuCS'tr1Q nrcld (xiS�YVi�S -from 4 Y p ' et.* r rrvcS ',./-‘ �.tr+hv.CQrrce Of -F\1e MI Won . / at\ 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. I also declare that I a duly authorized to sign this exemption application. sign ggm;niS+rq-l-or 2 /23 /2 , here I Authorized Sig ure Title Date r RECEIVED EIVED FeF-CcluntyTreasurer Recommendation i•• EXEMPT PER NSS#77-202 Approval Comments: ❑Denial F E B 2 5 2026 3. guLkwat' HALL COUNTY Signature of County Treasurer i TPFASUFli PS OFFICE Gi•INN,ist_'Nu.ru_HP/SKA Fnr ftnt.1ty Board of Equalization Use Only proved If the County Board's determination is different from the County Treasurer's recommendation,an explanation is required. ❑ Denied I declare that to the best o m knowled nd belief,the determination made by the County Board of Equar 'on is correct the/best t to he I of the State of Nebraska. /Sig'ature of Countj/B rd Member 4‘210.4 V Rev.7-2024 Authorized by Neb.Rev.Stat.§§77-202(1)(c)and(d).and 60-3,185,and 60-3,189 Please retain a copy for your records.