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MARK CHURCH
EF-60-AH-R17-0518-41000886-1 Assessor - County Clerk - Recorder
BOE-60-AH (P1) REV. 17 (0518)- 555 County Center
Redwood City, CA 94063
CLAIM OF PERSON(S) AT LEAST 55 YEARS OF P 650.363.4500 F 650.599.7435
email assessor@smcacre.org
AGE FOR TRANSFER OF BASE YEAR VALUE TO web www.smcacre.org
REPLACEMENT DWELLING
(INTRACOUNTY AND INTERCOUNTY, WHEN APPLICABLE)
A. REPLACEMENT DWELLING
ASSESSOR’S PARCEL NUMBER RECORDER’S DOCUMENT NUMBER
DATE OF PURCHASE DATE OF COMPLETION OF NEW CONSTRUCTION
PURCHASE PRICE COST OF NEW CONSTRUCTION
$ $
PROPERTY ADDRESS (street, city, county)
Is the new construction described performed on a replacement dwelling which has already been granted the benefit under section 69.5 within the past two
years? Yes No If yes, what was the date of your original claim?
B. ORIGINAL (FORMER) PROPERTY
ASSESSOR’S PARCEL NUMBER
DATE OF SALE SALE PRICE
$
PROPERTY ADDRESS (street, city, county)
Was this property your principal place of residence? Yes No
Did this property transfer to your parent(s), child(ren) or grandchild(ren)? Yes No
Note: When applicable, if the property is located in a different county from that of the replacement property, you must attach a copy of
the original property’s latest tax bill and any supplemental tax bill(s) issued before the date of sale. Also, was there any new construction
to this property since the last tax bill(s) and before the date of sale? Yes No
If yes, please explain:
Was this property substantially damaged or destroyed by misfortune or calamity (not a Governor-declared disaster) and sold in its damaged
state? Yes No If yes, what was the date of the misfortune or calamity?
C. CLAIMANT INFORMATION (please print)
NAME OF CLAIMANT (provide copy of valid identification with date of birth) SOCIAL SECURITY NUMBER DATE OF BIRTH AT LEAST AGE 55?
Yes No
NAME OF SPOUSE (provide if the spouse is a record owner of the replacement dwelling) SOCIAL SECURITY NUMBER DATE OF BIRTH AT LEAST AGE 55?
Yes No
Have either you or your spouse previously been granted relief under section 69.5 because of disability? Yes No
Have either you or your spouse previously been granted relief under section 69.5? Yes No
If yes,have you or your spouse subsequently become severely and permanently disabled? Yes No
CERTIFICATION
I/we certify (or declare) under penalty of perjury under the laws of the State of California that: (1) as a claimant/occupant I/we occupy the
replacement dwelling described above as my/our principal place of residence; (2) as a claimant I/we were at least 55 years of age at the
time of the sale of our original residence; and (3) the foregoing, and all information hereon, is true, correct, and complete to the best of
my/our knowledge and belief.
tSIGNATURE OF CLAIMANT DATE
tSIGNATURE OF SPOUSE DATE
MAILING ADDRESS DAYTIME PHONE NUMBER
( )
CITY, STATE, ZIP EMAIL ADDRESS
If there are not enough spaces above for additional claimant(s) information, please use the above format on a separate sheet of paper and attach. If you
have any questions about this form, please contact the Assessor’s Office.
Note: Unless you become disabled at a later date, this may be a one-time only exclusion.
All information provided on this form is subject to verification.
IF YOUR APPLICATION IS INCOMPLETE, YOUR CLAIM MAY NOT BE PROCESSED.
THIS CLAIM IS NOT SUBJECT TO PUBLIC INSPECTION
