Form Boe-267-H - Welfare Exemption Supplemental Affidavit Form, Housing - Elderly Or Handicapped Families Eligibility Based On Family Household Income Page 3

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BOE-267-H (S2F) REV. 6 (8-06)
ELDERLY OR HANDICAPPED FAMILIES
STATEMENT OF FAMILY HOUSEHOLD INCOME
(SUGGESTED FAMILY HOUSEHOLD INCOME REPORTING FORM)
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
INCOME LIMIT
NAME(S) OF OCCUPANTS
FAMILY HOUSEHOLD
1
$
2
$
3
$
4
$
5
$
6
$
7
$
8
$
If there is more than one person residing in a unit, do you consider yourselves a family?
Yes
No
If no, report on line 1 the number of persons in your family. Each nonfamily member must complete a separate statement.
(See instructions.)
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 family household.)
SIGNATURE
TITLE
DATE

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