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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />5. If the source of IGT funding is from taxes, please answer the following questions: <br />a. Is the tax a state, county, city, or hospital district tax? <br />County I <br />f other, please explain <br />b. What entities are taxed? <br />c. WI- <br />CnTiTh <br />'roperty <br />it is the tax structure (i.e. property tax, percentage of revenue, assessment, etc.)? <br />'roperty Tax <br />it is the amount or percent or the tax <br />?.3531 mills <br />e. Does at least 85% of the burden of the tax revenue fall on health care providers as defined in 42 <br />CFR §433.55? (Provide the total tax revenue and the health care provider tax burden) If so, please <br />answer the following questions: <br />Amount <br />Total Tax Burden $ - <br />Healthcare Provider Tax Burden $ - <br />0.00% <br />i) Is the tax broad based? A broad based tax can be defined as a tax that is imposed on at least <br />all health care items or services in the class or providers of such items or services furnished by <br />all non -Federal, non-public providers in the State, and is imposed uniformly, pursuant to 42 <br />CFR § 433.68. <br />F no, please explain <br />