Form Boe-267-R - Welfare Exemption Supplemental Affidavit, Rehabilitation - Living Quarters - 2011
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3BOE-267-R (P1) REV. 07 (06-11)
WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,
REHABILITATION — LIVING QUARTERS
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)
Section 1. Identification of Applicant
Name of Organization
Mailing Address (number and street)
Corporate ID or LLC Number
City, State, Zip Code
Organizational Clearance Certificate (OCC) No. __________________________ (Provide copy of certificate with this claim if first filing). If you do not have
an OCC, have you filed a claim for an OCC with the BOE?
Yes
No
If No, see instructions for information on obtaining an OCC claim form.
Section 2. Identification of Property
Address of property (number and street)
City, County, Zip Code
Date Property Acquired
Section 3. Rehabilitation
Provide a copy of the organization’s formal rehabilitation program, or describe the rehabilitation program and activities in detail on a separate
attachment.
A. Thrift shop, workshop, manufacturing, or similar activities.
1. Number of hours per week the facility is operated:
Total number of persons employed on the premises on January 1.
2. Persons being rehabilitated. Full-time:
Part-time:
Identify the number of persons being rehabilitated based on the length of employment:
Less than 6 months:
6 months - 1 year:
1 year - 2 years:
Longer than 2 years:
(list by number of years)
3. Staff and/or others. Full-time:
Part-time:
B. Total number employed off the premises, but in the operations of the facility as of January 1.
1. Persons being rehabilitated. Full-time:
Part-time:
Identify the number of persons being rehabilitated based on the length of employment:
Less than 6 months:
6 months - 1 year:
1 year - 2 years:
Longer than 2 years:
(list by number of years)
2. Staff and/or others. Full-time:
Part-time:
C. Total number of hours worked during the time period included in the financial statements that accompany the claim.
1. Persons being rehabilitated.
Number of hours worked:
Number of persons involved:
2. Staff and/or others.
Number of hours worked:
Number of persons involved:
FOR ASSESSOR’S USE ONLY
Whom should we contact during normal business
hours for additional information?
Received by
(Assessor’s designee)
NAME
of
on
(county or city)
(date)
DAYTIME TELEPHONE
EMAIL ADDRESS
(
)
THIS DOCUMENT IS SUBJECT TO PUBLIC INSPECTION
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