Fill - Free fillable WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT, (140% AMI) HOUSEHOLDS EXCEEDING (County of Lake) PDF form

BOE-267-L3 (P1) REV 02 (05-19)

Corporate ID or LLC Number

Name of Organization

Address of Property (number and street)

City, County, Zip Code

This claim is led for scal year 20 _____

WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,

HOUSEHOLDS EXCEEDING LOW-INCOME LIMITS — "OVER-INCOME" TENANT DATA

(140% AMI)

This is a Supplemental Adavit led with

In the case of a property eligible for and receiving federal low-income housing tax credits pursuant to Internal Revenue Code Section 42, a

unit shall continue

to be treated as occupied by a lower income household for welfare exemption purposes of Revenue and Taxation Code

section 214(g), even if on subsequent lien dates the household income exceeds the lower income threshold, provided that:

(1) the occupants' household income is no more than 140 percent of area median income (AMI), adjusted for family size,

(2) the occupants were a lower income household on the lien date when occupancy rst began, and

(3) the unit remains rent-restricted.

You must complete this adavit if you checked the box in Section 4.A2 of BOE-267-L or BOE-267-L1, indicating that you are seeking exemption

on a unit under the provisions of Revenue and Taxation Code section 214(g)(2)(A)(iii).

SECTION 1. IDENTIFICATION OF APPLICANT AND IDENTIFICATION OF PROPERTY

— 20 _____

BOE-267, Claim for Welfare Exemption (First Filing)

BOE-267-A, Claim for Welfare Exemption (Annual Filing)

SECTION 2. HOUSEHOLD INFORMATION

A. List of Qualied Households

Section 259.15 of the Revenue and Taxation Code provides that for scal years 2018-19 to 2027-28, the claim for welfare exemption on a lower

income rental housing property that is eligible for and has received federal low-income housing tax credits, where the claimant seeks exemption

on units occupied by households whose incomes rise above the lower income limit but do not exceed 140 percent of area medium income, shall

be accompanied by an adavit that reports specic information. Use the table below to provide the required information, listing all such units

where the occupant initially met the income limitation and the unit continues to be rent restricted, as they may continue to be treated as lower

income units under the provision of section 214(g)(2)(A)(iii) of the Revenue and Taxation Code. Provide information for each unit that was included

on BOE-267-L or BOE-267-L1 in Section 4.C2 (Number of residential units occupied by households exceeding lower income limits, but do not

exceed 140% AMI ("over-income" tenants)). Attach additional sheets, if necessary.

Address/Unit Number

No. of Persons in Annual Household

Actual Rent

Household Income

Charged to

the Tenant

Maximum Allowable

Rent That Can Be

Charged for the Unit

CERTIFICATION

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing and all information contained herein, including

any accompanying statements or documents, is true, correct, and complete to the best of my knowledge and belief.

NAME OF CLAIMANT

TITLE

DATE

SIGNATURE OF CLAIMANT

DAYTIME TELEPHONE

( )

EMAIL ADDRESS

TCAC Number

THIS DOCUMENT IS CONFIDENTIAL AND IS NOT SUBJECT TO PUBLIC DISCLOSURE

BOE-267-L3 (P2) REV 02 (05-19)

INSTRUCTIONS FOR FILING

WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT,

HOUSEHOLDS EXCEEDING LOW-INCOME LIMITS — "OVER-INCOME" TENANT DATA (140% AMI)

This adavit must be led when seeking the welfare exemption on lower income rental housing property under the provisions

of Revenue and Taxation Code sections 214(g)(2)(A)(iii) and 259.15. These provisions are only applicable to lower income

rental housing properties eligible for and receiving federal low-income housing tax credits (LIHTC) pursuant to Internal Revenue

Code Section 42 and owned and operated by a nonprot organization, eligible limited liability company, or limited partnership

with an eligible managing general partner. Under these provisions, the welfare exemption continues to be available where the

occupant(s) of a unit originally met the lower income threshold on the lien date in the scal year in which the occupancy of the

unit commenced, but the household income of the occupants increased in subsequent years above the lower income limits,

as long as the income does not exceed 140 percent of area median income (AMI), adjusted for family size ("over-income"

tenants), and the unit continues to be rent restricted.

This adavit supplements the claim for welfare exemption and must be led, for certain properties, with the county assessor

by February 15 to avoid a late-ling penalty as provided for in Revenue and Taxation Code section 270. A separate adavit

must be led for each location upon which you are seeking exemption under the provisions of Revenue and Taxation Code

section 214(g)(2)(A)(iii). If you indicated on supplemental adavit BOE-267-L, Welfare Exemption Supplemental Adavit,

Housing – Lower Income Households, or BOE 267-L1, Welfare Exemption Supplemental Adavit, Low-Income Housing

Property Of Limited Partnership, that you are seeking exemption under this criteria, you must complete and le this form.

Failure to do so will result in denial of the exemption. In accordance with Revenue and Taxation Code section 259.15, the

assessor shall keep this form condential.

FISCAL YEAR

The scal year for which an exemption is being sought must be entered correctly. The proper scal year would be the

scal year that follows the lien date (12:01 a.m., January 1) for which the taxable or exempt status of the property is being

determined. For example, a person ling a timely claim in February 2018 would enter scal year "2018-2019" on their claim

form. However, an entry of "2017-2018" on a claim form led in February 2018 would signify that a late claim was being led

for the preceding scal year.

SECTION 1. Identication of Applicant Property

Identify the name of the organization seeking exemption on the low-income housing property, the corporate identication

number or LLC number assigned by the California Secretary of State, and the Tax Credit Allocation Committee (TCAC) number

assigned to the rental housing project. Identify the location of the low-income housing property and the county in which the

property is located.

SECTION 2. Household Information

Provide the requested household information on all units occupied by households for which the organization is seeking

exemption under the provisions of Revenue and Taxation Code section 214(g)(2)(A)(iii), as indicated upon checking the box in

Section 4.A2 on BOE-267-L or BOE 267-L1. This listing shall be those units included in the number of residential units

occupied by households exceeding lower income limits but do not exceed 140% AMI shown in Section 4.C2 on BOE-267-L

or BOE 267-L1.

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WELFARE EXEMPTION SUPPLEMENTAL AFFIDAVIT, (140% AMI) HOUSEHOLDS EXCEEDING (County of Lake)

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