MARK CHURCH
EF-267-H-R08-0611-41000806-1                                                          Assessor - County Clerk - Recorder
BOE-267-H (P1) REV. 08 (06-11)                                                        555 County Center
WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,                                             Redwood City, CA 94063
                                                                                      P 650.363.4500    F 650.599.7435
HOUSING – ELDERLY OR HANDICAPPED FAMILIES                                             email assessor@smcacre.org
This Claim is Filed for Fiscal Year 20 _____ —  20 _____ .                            web www.smcacre.org

This is a Supplemental Affidavit filed with
   BOE-267, Claim for Welfare Exemption (First Filing)
   BOE-267-A, Claim for Welfare Exemption (Annual Filing)

Section 1. Identification of Applicant
Name of Organization

Mailing Address (number and street)                                                   Corporate ID or LLC Number

City, State, Zip Code

Organizational Clearance Certificate (OCC) No. __________________________ (Provide copy of certificate with this claim if first filing).  If you do not have 
an OCC, have you filed a claim for an OCC with the BOE?    
 Yes         No  
If No, see instructions for information on obtaining an OCC claim form.
Section 2. Identification of Property 
Address of property (number and street)

City, County, Zip Code                                                                Date Property Acquired

Section 3. Household Information 

   A.  Eligibility Based on Family Household Income
   Section 214(f) of the California Revenue and Taxation Code provides that property owned by nonprofit organizations providing housing for low- and 
   moderate-income elderly or handicapped families can qualify for the welfare exemption from property taxes only to the extent that household incomes 
   of families residing there do not exceed amounts listed below:

   NO. OF PERSONS IN           MAXIMUM INCOME        NO. OF PERSONS IN MAXIMUM INCOME NO. OF PERSONS IN                    MAXIMUM INCOME
      HOUSEHOLD                                            HOUSEHOLD                  HOUSEHOLD
            1                              $99,450         4                 $142,100                         7            $176,200

            2                              $113,700        5                 $153,450                         8            $187,550

            3                              $127,900        6                 $164,850

   Note: If a dollar amount is not entered for each number of persons, contact the County Assessor for the figures.  The amounts are different for each 
   county and change annually.
   In order to qualify all or a portion of the property for the exemption, you must have: (1) a signed statement for each family that qualifies (you should 
   keep the statement for future audits); and (2) you must complete the report on pages 2 and 3 of this claim.

            FOR ASSESSOR’S USE ONLY                                    Whom should we contact during normal business 
                                                                             hours for additional information?
Received by                    (Assessor’s designee)       NAME

of      (county or city)        on            (date)       DAYTIME TELEPHONE                                  EMAIL ADDRESS
                                                           (      )
                                     THIS DOCUMENT IS SUBJECT TO PUBLIC INSPECTION

EF-267-H-R08-0611-41000806-2
BOE-267-H (P2) REV. 08 (06-11)
   B.  List of Qualified Families
   Complete or attach list showing desired information for only those households that qualify; use additional sheets if necessary.

         ADDRESS / UNIT NUMBER                       NO. OF PERSONS IN FAMILY               MAXIMUM INCOME FOR FAMILY
 (use two lines if there are two families in a unit) (may be more than one family in unit)                    DOES NOT EXCEED

1.                                                                                         $

2.                                                                                         $

3.                                                                                         $

4.                                                                                         $

5.                                                                                         $

C.  Recap for All Families, Eligible and Ineligible                                                           EXAMPLE             ACTUAL

1.Number of qualified families. (one for each line filled in above)                                           110

2.Number of non-qualified families. (Occupants did not sign statement, refused to report, amount of income is        10
 over the limit, or unit was occupied by other than elderly or handicapped family)
3.Total number of families.                                                                                   120

D.  Exemption Calculation                                                                                     EXAMPLE             ACTUAL

Percentage which the number of low and moderate-income elderly and handicapped families occupying the         110 / 120           /
property is of the total number of families occupying the property.
Maximum percentage of value of property eligible for exemption.                                               91.66%

                                                                    CERTIFICATION
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing and all information contained herein, including 
         any accompanying statements or documents, is true, correct, and complete to the best of my knowledge and belief.
NAME                                                                              TITLE                                           DATE

SIGNATURE
t

EF-267-H-R08-0611-41000806-3
BOE-267-H (P3) REV. 08 (06-11)

                                          INSTRUCTIONS FOR FILING
                              WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT
                              HOUSING – ELDERLY OR HANDICAPPED FAMILIES

FILING OF AFFIDAVIT
This affidavit is required under the provisions of sections 214(f), 251, and 254.5 of the Revenue and Taxation code and must 
be filed when seeking exemption on housing for elderly or handicapped families that is owned and operated by a nonprofit 
organization or eligible limited liability company.  A separate affidavit must be filed for each location and the income of the 
occupants must not exceed certain limits (see section 3 of claim form). This affidavit supplements the claim for welfare 
exemption and must be filed with the county assessor by February 15 to avoid a late filing penalty under section 270.  If 
you do not complete and file this form, you may be denied the exemption.  The claimant should provide each family living 
on the property with a copy of form BOE-267-H-A, Elderly and Handicapped Families, Family Household Income Reporting 
Worksheet. 

The organization keeps the completed, signed worksheet in case of further audit. Do not submit the worksheets with 
your filing.

FISCAL YEAR
The fiscal year for which an exemption is sought must be entered correctly. The proper fiscal year follows the lien date (12:01 
a.m., January 1) as of which the taxable or exempt status of the property is determined. For example, a person filing a timely
claim in February 20 would enter “20-20” on line four of the claim; a “20-2011” entry on a claim filed in February 
2011 would signify that a late claim was being filed for the preceding fiscal year.

SECTION 1.  Identification of Applicant.
Identify the name of the organization seeking exemption on the elderly or handicapped housing property, corporate identification 
number (or limited liability number if the organization is a limited liability company), and mailing address.

SECTION 2.  Identification of Property.
Identify the location of the elderly or handicapped housing property, county in which the property is located, and the date the 
property was acquired by the organization.

SECTION 3.  Household Information.
Include a list of low and moderate-income elderly and handicapped families that qualify for exemption based on the maximum 
income level for the county for the claim year where the property is located (see dollar amount on table).

OBTAINING CLAIM FORMS FROM THE STATE BOARD OF EQUALIZATION
Claim form BOE-277, Claim for Organizational Clearance Certificate – Welfare Exemption, is available on the Board’s website 
(www.boe.ca.gov) or you may request the form by contacting the Exemptions Section at 916-274-3430.