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Form: BOE-267-L-A



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 140 percent of area median income, or exceeded 140 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 140% AMI limit) for the number of persons shown online 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.

Household Income:
Income includes but is not limited to:

  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.
  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.
  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.

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. Amounts of 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.

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for 2022