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CLAIM FOR WELFARE EXEMPTION (ANNUAL FILING) To receive the full exemption, a claimant must complete and file this form with the Assessor by February 15. Organization Name and Mailing Address: (Make necessary corrections in ink to the printed name and address.) TITLE DATE Last year your organization received the Welfare Exemption for all or part of the property your organization owns at the location listed above. To continue receiving the exemption for the property you own at this location, you must complete, sign and return this claim form to the Assessor. A separate claim form is required for each location. The Assessor may contact you for additional information. A. If you no longer seek an exemption at this location, check here , sign and return this form to the Assessor. Date Vacated: B. If your organization is dissolved and therefore no longer needs an Organizational Clearance Certificate, check here C. Check, if changed within the last year: Mailing Address Organization Name D. Does your organization have a valid Organizational Clearance Certificate (OCC) issued by the State Board of Equalization? If yes, enter OCC No. and date issued Property Location: BOE-267-A (P1) REV. 20 (05-19) 20 Property No.: Class: YES NO Since January 1, last year: 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 CLAIMANT u ASSESSOR'S USE ONLY EMAIL ADDRESS Approved: ALL PART Denied Reason(s) for Denial: DAYTIME TELEPHONE ( ) NAME OF PERSON TO CONTACT FOR ADDITIONAL INFORMATION (please print) THIS DOCUMENT IS SUBJECT TO PUBLIC INSPECTION E. Have you amended the organization's formative documents articles of incorporation, constitution, trust instrument, articles of organization) since last year? Yes No If yes, please mail a copy of the amendment to the State Board of Equalization, County-Assessed Properties Division, P.O. Box 942879, Sacramento, CA 94279-0064. Please include your OCC number. Note to Assessor’s Office: If the organization is dissolved or the formative documents were amended, please forward a copy of this page to the Board of Equalization. Read the information on the reverse side before completing. All questions must be answered. If the answer to any question is “YES,” explain in an attachment or complete the referenced form. Contact the Assessor if any forms referenced below are needed to complete this application. Identify the property that your organization owns at this location: Real property (land/buildings/improvements) Personal property Taxable Possessory Interest This organization owns rents/leases the real property at this location: Donald O'Connor Alpine County Assessor/Recorder PO Box 155 Markleeville, CA 96120 Ph: (530) 694-2283 ---PAGE BREAK--- BOE-267-A (P2) REV. 20 (05-19) GENERAL INFORMATION The Welfare Exemption is available only to property, real or personal, owned by a religious, charitable, hospital, or scientific organization and used exclusively for religious, charitable, hospital, or scientific purposes. It is also available on a taxable possessory interest in publically owned real property used for exempt purposes by an organization that qualifies for the welfare exemption. A public owner is a local, state or federal agency. To be eligible for the full exemption, the claimant must file a claim each year on or before February 15. Only 90 percent of any tax, penalty, or interest may be canceled or refunded when a claim is filed between February 16 and December 31 of the current year. If the application is filed on or after January 1 of the next year, only 85 percent of any tax, penalty, or interest may be canceled or refunded. The tax, penalty, and interest for a given year may not exceed $250. A separate claim must be completed and filed for each property for which exemption is sought. In accordance with Revenue and Taxation Code section 254.5(b)(2), the assessor may institute an audit or verification of the property’s use to determine whether both the owner and user of the property meet the requirements of Revenue and Taxation Code section 214. ORGANIZATIONAL CLEARANCE CERTIFICATE The Assessor may not approve a property tax exemption claim until the claimant has been issued a valid Organizational Clearance Certificate (OCC) by the State Board of Equalization. If you are seeking exemption on this property, you must provide the organization's OCC No. and date issued. A listing of organizations with valid OCCs is available on the Board's website (www.boe.ca.gov) and can be accessed at www.boe. ca.gov/proptaxes/welfareorgeligible.htm. You may also contact the Board at 1-[PHONE REDACTED]. HOUSING If question 5 is answered yes, describe the portion of the property used for living quarters (since January 1 of the prior year). Submit documentation, including tenets, canons, or written policy, that indicates the organization requires housing be provided to employees and/or volunteers, or include statement why such housing is incidental to and reasonably necessary for the exempt purpose of the organization. If the documentation described in items or has been submitted in a previous year for this location, please submit documentation including the occupant's position or role in the organization with a statement indicating that the housing continues to be used for organization's exempt purpose. (This question is not applicable where the exempt activity is providing housing.) USE OF THE PROPERTY BY OTHER ORGANIZATIONS If question 8 is answered yes, and your organization’s real property is used by another party submit BOE-267-O. If another party only uses your personal property, then submit an attachment providing the requested information for such personal property and confirm that no real property is used by other parties. The lease does not need to be provided if furnished in a prior year. UNRELATED BUSINESS TAXABLE INCOME If question 9 is answered yes, you must attach the following to the claim: • the organization's information and tax returns, including Form 990-T, filed with the Internal Revenue Service for its immediately preceding year; • a statement setting forth the amount of time devoted to the organization's income-producing and to its non income-producing activities and, where applicable, a description of that portion of the property on which those activities are conducted; • a statement listing the specific activities and locations which produce unrelated business taxable income; and • a statement setting forth the amount of income of the organization that is attributable to activities in this state and is exempt from income or franchise taxation and the amount of total income of the organization that is attributable to activities in this state. ASSESSOR'S USE ONLY ASSESSED VALUES ITEM TOTAL ASSESSED VALUE OF: LAND IMP ROVEMENTS PERSONAL PROPERTY FIXTURES TOTAL ITEM EXEMPTION ALLOWED LAND IMP ROVEMENTS PERSONAL PROPERTY FIXTURES TOTAL If another exemption, such as the church, religious, etc., was allowed this year on a portion of the property described in the claim, indicate the type and amount of the exemption: $ (type) (amount) By (Assessor or designee) (date)