MARK CHURCH
EF-266-E-R01-0611-41000417-1                                             Assessor - County Clerk - Recorder
BOE-266-E (P1) REV. 01 (06-11)                                           555 County Center
                                                                         Redwood City, CA 94063
OWNERSHIP STATEMENT                                                      P 650.363.4500    F 650.599.7435
                                                                         email assessor@smcacre.org
COOPERATIVE HOUSING CORPORATION                                          web www.smcacre.org
This statement represents a written request from the Assessor. 
Failure to file will result in the assessment of a penalty.
FILE THIS STATEMENT BY FEBRUARY 1.

     NAME AND MAILING ADDRESS
     (Make necessary corrections to the printed name and mailing address)

PROPERTY STREET ADDRESS                                                            ASSESSOR’S PARCEL NUMBER 

CITY                                                                               ZIP CODE

                                  OWNERSHIP INFORMATION.

Attach a listing that provides:

 1. the full name and mailing address of each owner, stockholder, or holder of an ownership interest;
 2. a copy of the stock certificate or other document that evidences an interest in the unit or lot;
 3. the situs address, including the number, of each unit or lot;
 4. the date that an ownership interest was acquired and the acquisition price of that interest;
 5. which of the shareholders or members resided in the designated dwelling units on the lien date.

Copies of stock certificates and other documents evidencing an interest in an individual unit or lot that were provided to the 
Assessor in a previous ownership report are not required to be provided in subsequent ownership reports.

This statement must be filed on or before the first February 1 following an Assessor request, and on or before each February 
1 thereafter. Failure to file the ownership statement, shall result in a penalty described in Revenue and Taxation Code section 
482 for each individual unit or lot whose owner or shareholder fails to independently file the change in ownership statement. 

                                                           CERTIFICATION

I certify (or declare) that the foregoing and all information hereon, including any accompanying statements or documents, is 
true and correct to the best of my knowledge and belief.
tSIGNATURE OF CORPORATE OFFICER                                                    DATE

NAME OF CORPORATE OFFICER                                                TITLE

EMAIL ADDRESS                                                            DAYTIME TELEPHONE NUMBER
                                                                         (        )
                                THIS DOCUMENT IS SUBJECT TO PUBLIC INSPECTION