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					15-DPT-EX                                                STATE OF COLORADO                                                 PHONE (303) 866-2372
2010AMI.XLS                                        DIVISION OF PROPERTY TAXATION                                         1313 SHERMAN ST. #419
REV 01/10                                          DEPARTMENT OF LOCAL AFFAIRS                                               DENVER, CO 80203


                                                  OWNER'S OCCUPANCY REPORT
                                 TO BE COMPLETED ANNUALLY BY OWNERS OF PROPERTY
                            WHICH IS EXEMPT PURSUANT TO 39-3-109 (1)(b) AND/OR 39-3-112, C.R.S.

    The information given below must be valid as of January 1,        2010
I. Facility Information:
Owner Name and Mailing Address:                            File Number:
                                                                             Use the name and file number as it appears on the form
                                                                             supplied for this property location. Do not use information from
                                                                             forms for any other location.
                                                                         Property
                                                                         Location:
II. Income Limits:
     The following information may be obtained from the Colorado Housing and Finance Authority, or these HUD web pages:
       http://www.huduser.org/datasets/fmr.html                                http://www.huduser.org/datasets/il.html
A) What is 30% of the area median income for your facility for:
    One Resident                Two Residents       Three Residents          Four Residents              Five Residents              Six Residents


B) What is the Fair Market Rent per month for:
     Efficiency                 One Bedroom             Two Bedroom          Three Bedroom                 Four Bedroom              Five Bedroom


C) Multiply the Fair Market Rents by 12 to get the Annual Fair Market Rent:
     Efficiency                 One Bedroom             Two Bedroom          Three Bedroom                 Four Bedroom              Five Bedroom
$                 -         $                -      $             -      $                 -           $                 -       $              -

D) With the above information, complete the Worksheet for Qualification. Then, if units are shown to qualify, return to this page and
complete Section III.
III. Summary of Unit Qualification:
     Enter the total number of units in each subsection below based on the property's occupancy as of January 1.
     A. Total number of RENTED units (do not include demo units, vacant units, units occupied rent-free by staff, guest
     units, etc.):
     B. Total number of units rented on January 1 whose occupants and their Total Household Income qualified under one
     of the categories on the Worksheet for Qualification:
     C. Total number of units that did not meet the above requirements:

     D. If subsections A, B, and C, are completed correctly, A minus B minus C should equal zero. If this is not the case,
                                                                                                                                                     0
     please recheck your work, and correct as necessary.
IV. Signature and verification:
    I declare, under penalty of perjury in the second degree, that I have examined this report and any accompanying
    documents, and to the best of my knowledge and belief, it is true, correct and complete.
      Signature
                                                                                                 Date:
      Signatory:                                                                                 Phone:
                                                     Worksheet for Qualification
                                                Pursuant to 39-3-112 (1)(b.5) C.R.S.
Information given is valid as of January 1,           2010       File Number as on Owner's Occupancy Rpt:                    0
Section I.
    Answer the following questions for each unit whose total household income is less than the amounts given on the Occupancy Report,
    Section II. If the amount in Column H is less than or equal to the amount given in Column G, you will see a green "P" appear in
    Column H, indicating that the unit may possibly qualify. Continue to Section II. (Note: If any unit contains more than five bedrooms or
    more than six residents, this spreadsheet will not perform the necessary calculations to determine the unit's qualification. See below
    for further instructions.)
 A         B             C            D                E               F              G               H               I            J
Unit Name on   Number of          Number of      Total Annual       Monthly        30% of        Annual Rent     Annual Fair   Column I
 # Lease (Last Occupants          Bedrooms        Household        Rent Paid      Column E         Paid by         Market    Minus Column
     Name Only)                                    Income           for unit                      Residents       Rent for         H
                                                                                                                  this unit
                                                                                  $       -     $                            $      -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                  $       -     $                               $       -
                                                                                 $        -     $                               $        -
Section II.
   Complete this section only if there are units in Section I that may qualify (You'll see a green "P" to the right of Column H). If there are
   no such units, your facility does not qualify pursuant to 39-3-112 (1)(b.5) C.R.S.
   The following information may be obtained from a Notice of Valuation or Tax Bill for the property for the most recent tax year, the
   county assessor's website, if available, or by contacting your county assessor.
1) What is the total assessed value of this property?
     (Be sure to ask for assessed value rather than actual value.)
2) What is the mill levy for the property, expressed in decimal form?
     (A mill is 1/1000th of a dollar. Thus, 82.45 mills would be expressed in decimal form as 0.08245).
3) Multiply answer 1 by answer 2, to arrive at the total tax for the subject property.              $         -
     (Example: Assessed Value $200,000 X mill levy 0.08245 = $16,490.00)
     (Include rentable from are there in income was
4) How manyany units units which rental this facility? or could have been derived. Do not include units dedicated to non-rental uses, such
     as demo units, units occupied rent-free by staff or resident managers, etc.)
5) Divide the total tax by the number of rentable units in the facility to arrive at the total tax per unit:            #DIV/0!
     ($16,490 divided by 5 units = $3,298)
The number to the right of this text is the number of qualifying units on this page. If there is more than one page, add the numbers
together. This is the number that should be reported on your Owner's Occupancy Report, Section III, Item B. Any unit that does
not have a green "Q" in the final column is not qualified. If you feel there is an error, please review the instructions and check your  0
input.

				
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