MARK CHURCH
EF-267-H-A-R01-0611-41000825-1                                                            Assessor - County Clerk - Recorder
BOE-267-H-A (P1) REV. 01 (06-11)                                                          555 County Center
                                                                                          Redwood City, CA 94063
                                                                                          P 650.363.4500    F 650.599.7435
ELDERLY OR HANDICAPPED FAMILIES                                                           email assessor@smcacre.org
FAMILY HOUSEHOLD INCOME REPORTING WORKSHEET                                               web www.smcacre.org

Section 214(f) of the 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 for those units whose family household income 
does not exceed the limits stated here.

Promptly complete, sign and return this statement to the manager of the organization that provides the housing so the organization will have time 
to complete the form that must be filed with the Assessor.

                                         ADDRESS OR UNIT NUMBER
                                                           (NO P. O.  BOX NUMBERS)

                                                                                    NUMBER OF PERSONS IN
                                 NAME(S) OF OCCUPANTS                                                           INCOME LIMIT
                                                                                    FAMILY HOUSEHOLD
                                                                                          1                  $99,450

                                                                                          2                  $113,700

                                                                                          3                  $127,900

                                                                                          4                  $142,100

                                                                                          5                  $153,450

                                                                                          6                  $164,850

                                                                                          7                  $176,200

                                                                                          8                  $187,550

If more than one person is residing in a unit, do you consider yourselves a family?  Yes   No  

If NO, report on line 1 below the number of persons in your family. Each non-family member must complete a separate statement.

1. Number of persons in family household:

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 for the number of persons in the family household.)

NAME                                                        TITLE                                                         DATE

SIGNATURE
t
                                 NOTE TO MANAGER: RETAIN THIS FORM FOR YOUR RECORDS