Form Boe-267-H - Welfare Exemption Supplemental Affidavit Form, Housing - Elderly Or Handicapped Families Eligibility Based On Family Household Income

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BOE-267-H (S1F) REV. 6 (8-06)
WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,
HOUSING — ELDERLY OR HANDICAPPED FAMILIES
ELIGIBILITY BASED ON FAMILY HOUSEHOLD INCOME (Yearly Filing)
Carefully read and follow the accompanying instructions before preparing claim.
This affidavit is required under the provisions of sections 214(f), 251, and 254.5 of the Revenue and Taxation Code for those
organizations where the income of the occupants must not exceed certain limits.
This affidavit supplements the claim for welfare exemption and must be filed with the Assessor by February 15. Unless this form
is completed and filed, the exemption cannot be granted.
The claimant should provide each family living on the property with a copy of the attached form titled Elderly and Handicapped
Families — Statement of Family Household Income. (The organization keeps the completed, signed statements in case of further
audit.) The organization’s property will not be allowed the exemption unless the proper information in a completed affidavit is
provided to the Assessor.
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 mailing address including zip code)
4. for the property located at
,
(address of property including zip code)
5. this affidavit is submitted on behalf of the above organization in support of a claim for exemption for the 20
– 20
fiscal year.
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
THIS AFFIDAVIT IS A PUBLIC RECORD AND IS SUBJECT TO PUBLIC INSPECTION.

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