BOE-267-H-A

Source: https://www.boe.ca.gov/proptaxes/pdf/sample-boe267ha.pdf

This page watermarked sample only. Contact Assessor for actual form.

BOE-267-H-A (P1) REV. 02 (05-25)

ELDERLY OR HANDICAPPED FAMILIES FAMILY HOUSEHOLD INCOME REPORTING WORKSHEET

Section 214(f) of the Revenue and Taxation Code provides that property owned by nonprofit organizations providing housing for low- and moderate- income elderly or handicapped families can qualify for the welfare exemption from property taxes for those units whose family household income does not exceed the limits stated here.

Promptly complete, sign and return this statement to the manager of the organization that provides the housing so the organization will have time to complete the form that must be filed with the Assessor. ADDRESS OR UNIT NUMBER Form (NO P. O. BOX NUMBERS)

NUMBER OF PERSONS IN NAME(S) OF OCCUPANTS INCOME LIMIT FAMILY HOUSEHOLD ONLY Actual
1 $

2 $ for
3 $

4 $

5 $ Only
6 $

7 $ SAMPLE
8 $

If more than one person is residing in a unit, do you consider yourselves a family? Yes No

If NO, report on line 1 below the number of persons in your family. Each non-family member must complete a separate statement. Assessor

1. Number of persons in family household:

2. The family household income for the prior calendar year did not exceed $ ______________. (Enter the amount of the income limit shown for the number of persons in the family household.)Contact CERTIFICATION

   I certify (or declare) under penalty of the laws of the State of California that the foregoing, and all information herein, is true, correct, and complete to the best of my knowledge and belief.

NAME TITLE DATE

SIGNATURE t

NOTE TO MANAGER: RETAIN THIS FORM FOR YOUR RECORDS