MARK CHURCH
EF-267-L2-R01-1218-41000411-1                                                            Assessor - County Clerk - Recorder
BOE-267-L2(P1) REV. 01 (12-18)                                                           555 County Center
                                                                                         Redwood City, CA 94063
                                                                                         P 650.363.4500    F 650.599.7435
                                                                                         email assessor@smcacre.org
WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,                                                web www.smcacre.org
HOUSING — LOWER INCOME HOUSEHOLDS — TENANT DATA
This claim is filed for fiscal year 20 _____ —  20 _____
This is a Supplemental Affidavit filed with
        BOE-267, Claim for Welfare Exemption (First Filing)
        BOE-267-A, Claim for Welfare Exemption (Annual Filing)

In the case of a claim, for low-income rental housing property, owned and operated by an eligible nonprofit organization or eligible limited 
liability company, that does not receive government financing or receive low-income housing tax credits, may qualify for exemption up to a 
certain limit if 90 percent or more of the occupants of the property are lower income households whose rent does not exceed the rent prescribed 
by Section 50053 of the Health and Safety Code. The total exemption amount allowed under Revenue and Taxation Code section 214(g)(1)(C) 
to a taxpayer, with respect to a single property or multiple properties, may not exceed twenty million dollars ($20,000,000) in assessed value. 
You must complete this affidavit if you checked box C(3) in Section 3 of form BOE-267-L indicating you are seeking exemption under the 
provisions of section 214(g)(1)(C).

SECTION 1. IDENTIFICATION OF APPLICANT AND IDENTIFICATION OF PROPERTY

Name of Organization                                                                                   Corporate ID or LLC Number

Address of Property (number and street) 

City, County, Zip Code 

SECTION 2. HOUSEHOLD INFORMATION 

A. List of Qualified Households
Section 259.14 of the California Revenue and Taxation Code provides that claims on "qualified property" as described in section 214.17 shall include an 
affidavit reporting the following information on the units occupied by lower income households for which exemption is claimed: the actual household 
income, the maximum rent that can be charged to the household, and the actual rent. Use the table below to provide the required information. Attach 
additional sheets as necessary. Report information for each unit that was reported in Section 4, part B of form BOE-267-L.

                 Address/Unit Number                         No. of Persons in      Annual Household Maximum Allowable              Actual Rent 
                                                             Household                      Income     Rent That Can Be                Charged
                                                                                                       Charged

                                                              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 OF CLAIMANT                                                             TITLE                                           DATE

SIGNATURE OF CLAIMANT                                         DAYTIME TELEPHONE                        EMAIL ADDRESS
t                                                             (      )
                 THIS DOCUMENT IS CONFIDENTIAL AND IS NOT SUBJECT TO PUBLIC DISCLOSURE

EF-267-L2-R01-1218-41000411-2
BOE-267-L2 (P2) REV. 01 (12-18) 

                                                    INSTRUCTIONS FOR FILING 
                                WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT, 
                                HOUSING — LOWER INCOME HOUSEHOLDS — TENANT DATA

FILING OF AFFIDAVIT
This affidavit is required under the provisions of sections 214(g)(1)(C), 214.17, and 259.14 of the Revenue and Taxation Code 
and must be filed when seeking exemption on low-income housing property, owned and operated by a nonprofit  organization 
or eligible limited liability company, that does not receive government financing or state/federal low-income housing tax credits. 
A separate affidavit must be filed for each location upon which you are seeking exemption under the provisions of section 
214(g)(1)(C). This affidavit supplements the claim for Welfare Exemption and must be filed, for certain properties, with the 
County Assessor by February 15 to avoid a late filing penalty under section 270. If you indicated on supplemental affidavit form 
BOE-267-L that you seek exemption under the criteria of Revenue and Taxation code section 214(g)(1)(C), by checking box 
(C)(3) in SECTION 3 of that form, you must complete and file this form; failure to do so will result in denial of the exemption. 
In accordance with Revenue and Taxation Code section 259.14, the Assessor shall keep this information confidential.

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 2018 would enter “2018-2019” on line four of the claim; a “2017-2018” entry on a claim filed in February
2018 would signify that a late claim was being filed for the preceding fiscal year.

SECTION 1. Identification of Applicant and Property
Identify the name of the organization seeking exemption on the low-income housing property, corporate identification number 
or LLC number assigned by the California Secretary of State. Identify the location of the low-income housing property and 
county in which the property is located.

SECTION 2. Household Information
Provide the requested household information on all units occupied by lower income households for which the organization is 
seeking exemption. This listing must include all households for which exemption is sought in Section 4 of form BOE-267-L, 
Welfare Exemption Supplemental Affidavit, Housing –Lower Income Households.