BOE-267-L-B

Source: https://www.boe.ca.gov/proptaxes/pdf/sample-boe267Lb.pdf

This page watermarked sample only. BOE-267-L-B (P1) REV. 01 (05-25) Contact Assessor for actual form. LOWER INCOME HOUSEHOLDS FAMILY HOUSEHOLD INCOME REPORTING WORKSHEET (100% AMI) Section 214(g) of the California Revenue and Taxation Code provides that property owned by nonprofit organizations or eligible limited liability companies providing housing for lower income households can qualify for the Welfare Exemption from property taxes for those units whose family household income does not exceed the limits stated herein. Pursuant to section 214(g)(2)(A)(iii), for property that is subject to an enforceable and verifiable agreement with a public agency, units shall continue to qualify for exemption if the occupants were lower income households when they first moved into the unit, but whose income has subsequently increased to no more than 100 percent of area median income (AMI) (“over-income” tenants). 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 County Assessor to claim property tax exemption on qualifying units in the property.

Section 1. ADDRESS OR UNIT NUMBER (No P.O. Box Numbers)

Section 2. Number of Persons LowerFormIncome 100% AMI NAME(S) OF OCCUPANTS in Family Household Limit Limit 1 ONLY 2 Actual3

4 for
5

6

7 SAMPLE 8

Section 3. Assessor Check the applicable box to indicate which income limit applies to your household income forthe 20 calendar year, based on the number of persons in your household: Does not exceed lower income limit Exceeds lower income limit, but not greater than 100% of AMI Exceeds 100% AMI limit Section 4.1. NumberContactof persons in family household . This number should match the number of persons listed in Section 2 above. 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.)

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.

SIGNATURE PRINT NAME DATE ► NOTE TO MANAGER: RETAIN THIS FORM FOR YOUR RECORDS

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

BOE-267-L-B (P2) REV. 01 (05-25)

INSTRUCTIONS

LOWER INCOME HOUSEHOLDS

FAMILY HOUSEHOLD INCOME REPORTING WORKSHEET

Section 1. Enter the address or unit number of your household. Section 2. Enter the names of the persons who comprise your household. Section 3. Check the applicable box to indicate if your household income for the applicable number of persons in your household during the calendar year did not exceed the lower income limit, or exceeded the lower income limit but does not exceed 100 percent of area median income, or exceeded 100 percent of area median income. Section 4.

1. Enter the number of persons who comprise your household.
2. Enter the applicable income limit figure (lower income limit or 100% AMI limit) for the number of persons shown on Form line 1.
3. Sign the statement to certify the accuracy of the information provided.
4. Promptly return the statement to an officer or the manager of the organization on whose property you reside. ONLY Household Income: Income includes but is not limited to: Actual (1) Wages, salaries, fees, tips, bonuses, commissions and other employee compensation. (2) Net income from the operation of a business or profession or from rental of real or personal property. for (3) Interest and dividends. (4) Periodic payments received from social security, annuities, insurance policies, retirement funds, pensions, disability or other similar types of periodic receipts. (5) Unemployment and disability compensation, workers’ compensation and severance pay. (6) Public assistance exclusive of any amount specified for shelter and utilities. SAMPLE (7) Alimony, child support payments and regular contributions or gifts from persons not residing in the dwelling. (8) All regular pay, special pay and allowances of a member of the Armed Forces who is head of the household or spouse. Assessor The following items shall not be considered as income: (1) Casual, sporadic or irregular gifts. (2) Amounts specifically for or in reimbursement of the cost of medical expenses. (3) Lump-sum additions to family assets such as inheritances, insurance payments (including payments under health and accident insurance and workers’ compensation), capital gains and settlement for personal or property losses. (4) AmountsContactof educational scholarships paid directly to the student or to the educational institution and veteran benefits for costs of tuition, fees, books, and equipment. (5) The value of food coupons. (6) Payments received from the ACTION Agency, VISTA, Service Learning Programs, Special Volunteer Programs, National Older American Volunteer Program, Retired Senior Volunteer Program, Foster Grandparent Program, Older American Community Services Program, SCORE and ACE. (7) Foster Child Care payments.

For a complete listing of income and deductions, see Department of Housing and Community Development Regulations, section 6914 of Title 25 of the California Code of Regulations.