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Form Boe-267-H - Welfare Exemption Supplemental Affidavit Form, Housing - Elderly Or Handicapped Families Eligibility Based On Family Household Income Page 4

BOE-267-H (S2B) REV. 6 (8-06)

SUGGESTED FAMILY HOUSEHOLD INCOME REPORTING FORM

INSTRUCTIONS

1. Enter your address and/or unit number and the names of the persons who comprise your family.

2. Enter on line 1 the number of persons who comprise your family.

3. Enter on line 2 the income limit figure for the number of persons shown on line 1.

4. Sign the statement if your combined family income is the same as or less than the income limit.

5. Promptly return the statement to an officer or the manager of the organization on whose property you reside.

Household Income:

Income includes but is not limited to:

(1) Wages, salaries, fees, tips, bonuses, commissions and other employee compensation.

(2) Net income from the operation of a business or profession or from rental of real or personal property.

(3) Interest and dividends.

(4) Periodic payments received from social security, annuities, insurance policies, retirement funds, pensions, disability or

other similar types of periodic receipts.

(5) Unemployment and disability compensation, workers’ compensation and severance pay.

(6) Public assistance exclusive of any amount specified for shelter and utilities.

(7) Alimony, child support payments and regular contributions or gifts from persons not residing in the dwelling.

(8) All regular pay, special pay and allowances of a member of the Armed Forces who is head of the family or spouse.

The following items shall not be considered as income:

(1) Casual, sporadic or irregular gifts.

(2) Amounts specifically for or in reimbursement of the cost of medical expenses.

(3) Lump sum additions to family assets such as inheritances, insurance payments (including payments under health and

accident insurance and workers’ compensation), capital gains and settlement for personal or property losses.

(4) Amounts of educational scholarships paid directly to the student or to the educational institution and veteran benefits for

costs of tuition, fees, books, and equipment.

(5) The value of food coupons.

(6) Payments received from the ACTION Agency, VISTA, Service Learning Programs, Special Volunteer Programs, National

Older American Volunteer Program, Retired Senior Volunteer Program, Foster Grandparent Program, Older American

Community Services Program, SCORE and ACE.

(7) Foster Child Care payments.

For a complete listing of income and deductions, see Department of Housing and Community Development Regulations,

section 6914.

Form Boe-267-H - Welfare Exemption Supplemental Affidavit Form, Housing - Elderly Or Handicapped Families Eligibility Based On Family Household Income Page 4

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