MARK CHURCH
EF-236-A-R10-0518-41000807-1                                                                   Assessor - County Clerk - Recorder
BOE-236-A (P1) REV. 10 (05-18)                                                                 555 County Center
SUPPLEMENTAL AFFIDAVIT FOR BOE-236                                                             Redwood City, CA 94063
                                                                                               P 650.363.4500    F 650.599.7435
HOUSING — LOWER-INCOME HOUSEHOLDS                                                              email assessor@smcacre.org
ELIGIBILITY BASED ON FAMILY HOUSEHOLD                                                          web www.smcacre.org
INCOME (Yearly Filing)

This affidavit is required under the provisions of section 251 of the Revenue and Taxation Code for those organizations filing 
BOE-236, Exemptions of Leased Property Used Exclusively for Low-Income Housing.

This affidavit supplements the claim for exemption and must be filed with the Assessor. If you do not complete and file this 
form, it is grounds for denial of the exemption.

                                                                                                                                states:
                                               (name of person making affidavit)

 1. That as                                                                                                                          ,
                                                               (title, such as president, etc.)

 2. of the                                                                                                                           ,
                                                   (corporate or organization name)

 3. the mailing address of which is                                                                                                 ,
                                                                      (complete address including zip code)

 4. for the property located at                                                                                                     .
                                                               (address of property, including zip code)

 5. That this affidavit is made on behalf of the above organization in support of a claim for exemption for the
    20                          - 20  fiscal year. (Example: a person filing a timely claim in January 2011 would enter "2011-2012.")

                                     ELIGIBILITY BASED ON FAMILY HOUSEHOLD INCOME

Section 236 of the California Revenue and Taxation Code provides that property used exclusively for providing housing for 
lower-income households can qualify for an exemption from property taxes to the extent that incomes of households residing 
therein do not exceed amounts listed below:

 No. of Persons                      Maximum       No. of Persons            Maximum           No. of Persons            Maximum
    in Household                      Income       in Household                Income          in Household              Income
             1                        $82,200                4                  $117,400               7                 $145,600
             2                        $93,950                5                  $126,800               8                 $155,000
             3                        $105,700               6                  $136,200

NOTE:  If a dollar amount is not entered for each number of persons, contact the Assessor. The amounts are different for each 
    county and they change annually.

In order to qualify all or a portion of the total property for the exemption, you must have: (1) a signed statement for each  
household that qualifies (you keep the statement in case of further audit); and (2) you must complete the report on the reverse 
of this form.

                                                   CERTIFICATION

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

SIGNATURE OF PERSON MAKING AFFIDAVIT                           TITLE                                        DATE
t

               THIS AFFIDAVIT IS A PUBLIC RECORD AND IS SUBJECT TO PUBLIC INSPECTION.

EF-236-A-R10-0518-41000807-2
BOE-236-A (P2) REV. 10 (05-18)

A. LIST OF QUALIFIED HOUSEHOLDS

                              UNIT NUMBER    NUMBER OF PERSONS IN HOUSEHOLD                        MAXIMUM INCOME FOR 
    (use two lines if there are              (may be more than one                                 HOUSEHOLD DOES NOT
    two households in a unit)                 household in unit)                                               EXCEED 

1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 

B.NUMBER OF UNITS SERVING LOWER-INCOME HOUSEHOLDS                                                  EXAMPLE     ACTUAL
NOTE: The exemption percentage is the number of “units serving lower-income households
divided by the total number of residential units. This percentage is applied to the entire property
including “related facilities”.
 1. Number of residential units designated for use by or serving lower-income households.          80

2.Total number of residential units.                                                               100
3.Percentage which the number of “units serving lower-income households” is of the total
                                                                                                   80% (80/100)
number of residential units. (BN1 / B2 above)

EF-236-A-R10-0518-41000807-3
BOE-236-A (P3) REV. 10 (05-18)
                                 INSTRUCTIONS FOR COMPLETION OF
                                 SUPPLEMENTAL AFFIDAVIT FOR BOE-236
                                            Housing — Lower-Income Households
                                        Eligibility Based on Family Household Income

The claimant (organization) must follow the instructions listed below. The claimant should provide each household               
living on the property with a copy of the attached form titled Lower-Income Households  — Statement of Family Household         
Income. The organization’s property will not be allowed the exemption unless the proper information in a completed 
affidavit, in duplicate, is provided to the Assessor.

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 2011 would enter "2011-2012" on line four of the claim; a "2010-2011" entry on a claim filed in February 2011
would signify that a late claim was being filed for the preceding fiscal year.

A.LIST OF QUALIFIED HOUSEHOLDS
The claimant must list on the affidavit the following information for only those lower-income households that qualify:

(1) Home address, apartment number, room number, etc. Use two lines if there are two households at the same
    location, etc.

(2) The number of persons claimed to be in the household (one household for each line item).

(3) The maximum income limit reported by each household (this figure should agree with the income limit based upon the
    number of persons in the household that as printed on the affidavit).

NOTE:  No by line item reporting is necessary for vacant room (areas), households that did not report, households that may 
    not be lower-income, or for households whose incomes exceed the applicable income limits.

B.NUMBER OF UNITS SERVING LOWER-INCOME HOUSEHOLDS
The claimant must complete this section of the affidavit for all households, eligible and ineligible, by entering:

                                                                              Example

(1) The total number of households                                                  80

(2) The total number of residential units                                           100

(3) The exemption calculation percentage is computed by
    dividing the lower-income units B(1) by the total number                  80% (80/100)
    of units B(2)

EF-236-A-R10-0518-41000807-4
BOE-236-A (P4) REV. 10 (05-18)

                              (Suggested Family Household Income Reporting Form for  )
                                            LOWER-INCOME HOUSEHOLDS
                                         STATEMENT OF HOUSEHOLD INCOME

Promptly sign and file this statement by                     with an officer or the manager of the organization on whose 
property you reside.

          Name(s) of Occupants: 

          Address or Unit No.: 
          (No P.O. Box Nos.)

Complete the statement and return it to the manager of the organization that provides the housing.

1. Number of persons in family household (see instructions).

2. I certify (or declare) under penalty of perjury under the laws of the State of California that the family household income for
   the prior calendar year did not exceed $   . (Enter the amount of the income limit, shown below, for the number
   of persons in family household.)

                                   NUMBER OF PERSONS 
                                   IN FAMILY HOUSEHOLD      INCOME LIMIT

                                            1               $82,200
                                            2               $93,950
                                            3               $105,700
                                            4               $117,400
                                            5               $126,800
                                            6               $136,200
                                            7               $145,600
                                            8               $155,000

SIGNATURE                                      TITLE                                              DATE
t

EF-236-A-R10-0518-41000807-5
BOE-236-A (P5) REV. 10 (05-18)

                                 (FAMILY HOUSEHOLD INCOME REPORTING FORM)

                                              GENERAL INFORMATION

Section 236 of the California Revenue and Taxation Code provides that property used exclusively for providing housing for 
lower-income households can qualify for an exemption from property taxes.

                                                      INSTRUCTIONS

FAMILY HOUSEHOLD INCOME

1.  Enter the names of the persons who are in your household. Also, enter address or unit number.
2.  Enter on line 1 the number of persons who are in your household.
3.  Enter on line 2 the income limit figure for the number of persons shown on line 1.
4.  Sign the statement  ifyour combined household income is the same as or less than the income limit.
5.  Promptly return the statement to an officer or the manager of the organization on whose property you reside so the
    organization will have time to complete the form that must be filed with the Assessor.

HOUSEHOLD INCOME

Income includes but is not limited to:

    (1)  Wages, salaries, fees, tips, bonuses, commissions, and other employee compensation.
    (2)  Net income from the operation of a business or profession or from rental of real or personal property.
    (3)  Interest and dividends.
    (4)  Periodic payments received from social security, annuities, insurance policies, retirement funds, pensions,
         disability, or other similar types of periodic receipts.
    (5)  Unemployment and disability compensation, workers compensation and severance pay.
    (6)  Public assistance exclusive of any amount specified for shelter and utilities.
    (7)  Alimony, child support payments, and regular contributions or gifts from persons not residing in the dwelling.
    (8)  All regular pay, special pay, and allowances of a member of the Armed Forces who is head of the household or spouse.

The following items shall not be considered as income:

    (1)  Casual, sporadic, or irregular gifts.
    (2)  Amounts specifically for or in reimbursement of the cost of medical expenses.
    (3)  Lump sum additions to family assets, such as inheritances, insurance payments (including payments under health
         and accident insurance and workers’ compensation), capital gains, and settlement for personal or property losses.
    (4)  Amounts of educational scholarships paid directly to the student or educational institution and veteran benefits for
         costs of tuition, fees, books, and equipment.
    (5)  The value of food coupons.
    (6)  Payments received from the ACTION Agency, VISTA, Service Learning Programs, Special Volunteer Programs,
         National Older American Volunteer Program, Retired Senior Volunteer Program, Foster Grandparent Program, Older
         American Community Services Program, SCORE, and ACE.
    (7)  Foster Child Care payments.

For a complete listing of income and deductions, see Department of Housing and Community Development Regulations,             
section 6914.