Form Boe-267-R (P1) - Welfare Exemption Supplemental Affidavit, Rehabilitation - Living Quarters (Yearly Filing) Page 2

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COUNTY OF LOS ANGELES • OFFICE OF THE ASSESSOR

BOE-267-R (P2) REV. 05 (03-08) EXM-422 (REV. 8-08)

500 WEST TEMPLE STREET, ROOM 227

LOS ANGELES, CA 90012-2770 • Telephone 213.974.3481

Email: exempt@assessor.lacounty.gov

RICK AUERBACH

Website: assessor.lacounty.gov

ASSESSOR

Si desea ayuda en Español, llame al número 213.974.3211

REHABILITATION

On a separate sheet describe your rehabilitation program and activities in detail.

Thrift shop, workshop, manufacturing, or similar activities.

Number of hours per week the store or other facility is operated:

Total number of persons employed on the premises on January 1:

Persons being rehabilitated

Staff and/or others

Full-time __________________________

Full-time ____________________________

Part-time __________________________

Part-time ____________________________

Length of employment of persons being rehabilitated:

Number of persons, less than six months________________________

Number of persons, 6 months - 1 year __________________________

Number of persons, 1 year - 2 years ___________________________

Number of persons, longer than 2 years ________________________

(list by number of years)

Total number employed off the premises, but in the operations of the store or other facility as of January 1:

Persons being rehabilitated

Staff and/or others

Full-time __________________________

Full-time ____________________________

Part-time __________________________

Part-time ____________________________

Length of employment of persons being rehabilitated:

Number of persons, less than six months________________________

Number of persons, 6 months - 1 year __________________________

Number of persons, 1 year - 2 years ___________________________

Number of persons, longer than 2 years ________________________

(list by number of years)

D. Total number of hours worked during the time period included in the financial statements that accompany the claim:

Persons being rehabilitated

Staff and/or others

a. Number of hours worked _______________

a. Number of hours worked _________________

b. Number of persons involved _____________

b. Number of persons involved _______________

E. Salaries and wages paid during the time period included in the financial statements that accompany the claim:

Persons being rehabilitated

Staff and/or others

a. Salaries and wages ___________________

a. Salaries and wages _____________________

b. Number of persons involved _____________

b. Number of persons involved _______________

Does a person, management firm, or entity other than the organization filing this

claim operate the store or facility? ...................................................................................................................

Yes

If yes, please provide the operator’s name and mailing address: _________________________________________________

____________________________________________________________________________________________________

Amount of salary or fee (attach a copy of the contract or other document that indicates the

basis for the salary or fee): .............................................................................................................................. $ ___________

Is housing for persons being rehabilitated and/or living quarters for staff provided? .................................

Yes

If yes, explain the necessity and complete the section titled Housing — Living Quarters.