Form Boe-267-R (P1) - Welfare Exemption Supplemental Affidavit, Rehabilitation - Living Quarters (Yearly Filing) Page 3

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BOE-267-R (P3) REV. 05 (03-08) EXM-422 (REV. 8-08)

HOUSING — LIVING QUARTERS

(This section is to be completed if one or more persons lives on the premises.)

A. Total number of persons who were housed on the premises the last night in December (include persons who may be temporarily

away):

1. Number of persons being rehabilitated ....................................................................................................................

_______________

2. Number of unoccupied beds available for persons to be rehabilitated.....................................................................

_______________

3. Number of staff members necessary to care for those persons being rehabilitated (attach a

list which describes the job performed and the number of persons involved) ..........................................................

_______________

4. Number of other staff members ................................................................................................................................

_______________

5. Number of other persons who are not directly connected with the rehabilitation program.......................................

_______________

B. Length of stay of persons being rehabilitated who were housed on the premises the last night in December:

1. Number of persons

less than six months .................................................................................................................................................

_______________

6 months - 1 year .....................................................................................................................................................

_______________

1 year - 2 years ........................................................................................................................................................

_______________

2 years or longer (list by number of years) ..............................................................................................................

_______________

2. Total (this figure must agree with the total given above for persons being rehabilitated): ......................................

_______________

C. Do persons being rehabilitated pay, donate, or perform fund producing work for

their room and/or board? ..........................................................................................................................................

Yes

If yes, indicate which and explain in sufficient detail to determine the monthly fee per person.

____________________________________________________________________________________________________________

D. Do staff members who care for those being rehabilitated pay, donate, or perform

work for their room and/or board (in lieu of, or from their salary)? ......................................................................

Yes

If yes, indicate which and explain in sufficient detail to determine the monthly fee per person.

____________________________________________________________________________________________________________

E. Do other staff members pay, donate, or perform work for their room and/or board

(in lieu of, or from their salary)? ...............................................................................................................................

Yes

If yes, indicate which and explain in sufficient detail to determine the monthly fee per person.

____________________________________________________________________________________________________________

F. Do the other persons not directly connected with the rehabilitation program pay,

Yes

donate, or perform work for their room and/or board? ..........................................................................................

If yes, indicate which and explain in sufficient detail to determine the monthly fee per person.

____________________________________________________________________________________________________________