Free Suffolk Registry of Probate - Massachusetts

Commonwealth of Massachusetts

Declaration of Homestead
Be it known by these presents, that I,

________________________ of _______________________
(Type or print your name)
(Type or print your city or town)

in the County of __________________, in said Commonwealth, as a householder and being entitled to an estate of homestead in the land and buildings thereon, hereinafter described, do declare that I own and am possessed and occupy, or intend to occupy, said premises as my principal residence and homestead under Massachusetts General Laws, Chapter 188, as amended, to wit:

____________________________________________________
(Type or print street and number) (Type or print city or town)

being more particularly described in an instrument recorded in Book ______ Page_____ or,

am a permanently disabled person and submit herewith a certification of a Massachusetts-licensed physician attesting that I am permanently disabled as defined in said chapter of the General Laws.

" and, if the foregoing box is checked, I certify that I am at least sixty-two years of age, or, that I
Witness my hand and seal this _______ day of _______, 200 __

being more particularly described in documents relating to Certificate of Title Number _______

________________________
(Sign before a notary)

________________________
(Date)

_______, ss

Then personally appeared the above named___________________ and acknowledged the foregoing instrument to be his/her free act and deed, before me:

_______________________
(Notary Public/Justice of the Peace)

My commission expires:

_________________

This form is to be recorded at the Registry of Deeds for the county in which the property is located. After recording, the form is returned to the address you specify. Place that name and address here:

____________________ ____________________ ____________________