Form Boe-267-H - Welfare Exemption Supplemental Affidavit, Housing - Elderly Or Handicapped Families - 2011 Page 2

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BOE-267-H (P2) REV. 08 (06-11)

B. List of Qualified Families

Complete or attach list showing desired information for only those households that qualify; use additional sheets if necessary.

ADDRESS / UNIT NUMBER

NO. OF PERSONS IN FAMILY

MAXIMUM INCOME FOR FAMILY

DOES NOT EXCEED

(use two lines if there are two families in a unit)

(may be more than one family in unit)

C. Recap for All Families, Eligible and Ineligible

EXAMPLE

ACTUAL

1. Number of qualified families. (one for each line filled in above)

110

2. Number of non-qualified families. (Occupants did not sign statement, refused to report, amount of income is

over the limit, or unit was occupied by other than elderly or handicapped family)

3. Total number of families.

120

D. Exemption Calculation

EXAMPLE

ACTUAL

Percentage which the number of low and moderate-income elderly and handicapped families occupying the

110 / 120

property is of the total number of families occupying the property.

Maximum percentage of value of property eligible for exemption.

91.66%

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

TITLE

DATE

SIGNATURE