Orange: BOE-237-A

(Example: a person filing a timely claim in February 2011 would enter "2011-2012.")

• SUPPLEMENTAL AFFIDAVIT
  Name of Person Making Affidavit Title

  Name of Tribe or Tribally Designated Housing Entity

  Mailing Address (City, State, Zip Code)

  Address of Property (Number and Street)

  ELIGIBILITY BASED ON FAMILY HOUSEHOLD INCOME

  Section 237 of the California Revenue and Taxation Code provides that tribal housing occupied by or held for lower-income households can qualify for an exemption from property taxes to the extent that incomes and rents of households residing therein do not exceed amounts listed below:

  
  

  NOTE: In order to qualify all or a portion of the total property for the exemption:

  (1) you must have a signed statement for each household that qualifies (you keep the statement in case of further audit);
  (2) you must complete the report on the reverse of this form.

  CERTIFICATION

  
  

  I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing and all information hereon, including any accompanying statements or documents, is true, correct and complete to the best of my knowledge and belief.

  Signature of Person Making Affidavit Title

  
  

  A. LIST OF QUALIFIED HOUSEHOLDS

  (Complete or attach list showing desired information)

  
  

  B. RECAP FOR ALL FAMILIES, ELIGIBLE AND INELIGIBLE

  
  

  
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• FAMILY HOUSEHOLD
  Suggested Family Household Income Reporting Form for

  LOWER-INCOME HOUSEHOLDS STATEMENT OF HOUSEHOLD INCOME

  
  

  Promptly sign and file this statement by with an officer or the manager of the organization on whose property you reside.

  
  

  Name(s) of Occupants

  Address or Unit No.: (No P.O. Box Nos.)

  Complete the statement and return it to the manager of the organization that provides the housing.

  1. Number of persons in family household (see instructions).

  2. I certify (or declare) under penalty of perjury under the laws of the State of California that the family household income for the prior calendar year did not exceed $ (Enter the amount of the income limit, shown below, for the number of persons in family household.)

  No. of Persons in Family Household 1 2 3 4 5 6 7 8 Income Limit $40,500 $46,300 $52,100 $57,850 $62,500 $67,150 $71,750 $76,400

  
  

  Signature Title

  
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