MARK CHURCH
EF-267-L3-R02-0519-41000065-1                                                         Assessor - County Clerk - Recorder
BOE-267-L3 (P1) REV 02 (05-19)                                                        555 County Center
                                                                                      Redwood City, CA 94063
WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,                                             P 650.363.4500    F 650.599.7435
HOUSEHOLDS EXCEEDING LOW-INCOME LIMITS —                                              email assessor@smcacre.org
"OVER-INCOME" TENANT DATA (140% AMI)                                                  web www.smcacre.org
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 property eligible for and receiving federal low-income housing tax credits pursuant to Internal Revenue Code Section 42, a 
unit shall continue to be treated as occupied by a lower income household for welfare exemption purposes of Revenue and Taxation Code 
section 214(g), even if on subsequent lien dates the household income exceeds the lower income threshold, provided that: 
(1) the occupants' household income is no more than 140 percent of area median income (AMI), adjusted for family size,
(2) the occupants were a lower income household on the lien date when occupancy first began, and
(3) the unit remains rent-restricted.
You must complete this affidavit if you checked the box in Section 4.A2 of BOE-267-L or BOE-267-L1, indicating that you are seeking exemption 
on a unit under the provisions of Revenue and Taxation Code section 214(g)(2)(A)(iii).

SECTION 1. IDENTIFICATION OF APPLICANT AND IDENTIFICATION OF PROPERTY
Name of Organization                                                                  Corporate ID or LLC Number TCAC Number

Address of Property (number and street) 

City, County, Zip Code 

SECTION 2. HOUSEHOLD INFORMATION 
A. List of Qualified Households
Section 259.15 of the Revenue and Taxation Code provides that for fiscal years 2018-19 to 2027-28, the claim for welfare exemption on a lower 
income rental housing property that is eligible for and has received federal low-income housing tax credits, where the claimant seeks exemption 
on units occupied by households whose incomes rise above the lower income limit but do not exceed 140 percent of area medium income, shall 
be accompanied by an affidavit that reports specific information. Use the table below to provide the required information, listing all such units 
where the occupant initially met the income limitation and the unit continues to be rent restricted, as they may continue to be treated as lower 
income units under the provision of section 214(g)(2)(A)(iii) of the Revenue and Taxation Code. Provide information for each unit that was included 
on BOE-267-L or BOE-267-L1 in Section 4.C2 (Number of residential units occupied by households exceeding lower income limits, but do not 
exceed 140% AMI ("over-income" tenants)). Attach additional sheets, if necessary.
  Address/Unit Number                                   No. of Persons in       Annual Household Maximum Allowable               Actual Rent 
                                                        Household             Income             Rent That Can Be                 Charged to
                                                                                                 Charged for the Unit             the Tenant

                                                           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-L3-R02-0519-41000065-2
BOE-267-L3 (P2) REV 02 (05-19) 

                                           INSTRUCTIONS FOR FILING 
                               WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT, 
HOUSEHOLDS EXCEEDING LOW-INCOME LIMITS — "OVER-INCOME" TENANT DATA (140% AMI)

This affidavit must be filed when seeking the welfare exemption on lower income rental housing property under the provisions 
of Revenue and Taxation Code sections 214(g)(2)(A)(iii) and 259.15. These provisions are only applicable to lower income 
rental housing properties eligible for and receiving federal low-income housing tax credits (LIHTC) pursuant to Internal Revenue 
Code Section 42 and owned and operated by a nonprofit organization, eligible limited liability company, or limited partnership 
with an eligible managing general partner. Under these provisions, the welfare exemption continues to be available where the 
occupant(s) of a unit originally met the lower income threshold on the lien date in the fiscal year in which the occupancy of the 
unit commenced, but the household income of the occupants increased in subsequent years above the lower income limits, 
as long as the income does not exceed 140 percent of area median income (AMI), adjusted for family size ("over-income" 
tenants), and the unit continues to be rent restricted.

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 as provided for in Revenue and Taxation Code section 270. A separate affidavit 
must be filed for each location upon which you are seeking exemption under the provisions of Revenue and Taxation Code 
section 214(g)(2)(A)(iii). If you indicated on supplemental affidavit BOE-267-L, Welfare Exemption Supplemental Affidavit, 
Housing – Lower Income Households, or BOE 267-L1,      Welfare Exemption Supplemental Affidavit, Low-Income Housing 
Property Of Limited Partnership  , that you are seeking exemption under this criteria, 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 259.15, the 
assessor shall keep this form confidential.

FISCAL YEAR
The fiscal year for which an exemption is being sought must be entered correctly. The proper fiscal year would be the 
fiscal year that follows the lien date (12:01 a.m., January 1) for which the taxable or exempt status of the property is being 
determined. For example, a person filing a timely claim in February 2018 would enter fiscal year "2018-2019" on their claim 
form. However, an entry of "2017-2018" on a claim form filed in February 2018 would signify that a late claim was being filed 
for the preceding fiscal year.

SECTION 1. Identification of Applicant Property
Identify the name of the organization seeking exemption on the low-income housing property, the corporate identification 
number or LLC number assigned by the California Secretary of State, and the Tax Credit Allocation Committee (TCAC) number 
assigned to the rental housing project. Identify the location of the low-income housing property and the county in which the 
property is located.

SECTION 2. Household Information
Provide the requested household information on all units occupied by households for which the organization is seeking 
exemption under the provisions of Revenue and Taxation Code section 214(g)(2)(A)(iii), as indicated upon checking the box in 
Section 4.A2 on BOE-267-L or BOE 267-L1. This listing shall be those units included in the number of residential units 
occupied by households exceeding lower income limits but do not exceed 140% AMI shown in Section 4.C2 on BOE-267-L 
or BOE 267-L1.