DECLARATION OF HOMESTEAD
ELDERLY and/or DISABLED

I (We)________________________________________________________________________________

owning and occupying the premises at ________________________________________

located in _________________________________________, Massachusetts and (each) being 62 years of age or older or being physically or mentally disabled and because of such disability, am (are) not able to engage in substantial, gainful employment, which disability is evidenced by the attached certification:

the deed being recorded in Book _______, Page ______ in the ESSEX SOUTH DISTRICT REGISTRY OF DEEDS

OR

as Certificate of title number ______________ registered in the Land Registration Office of the ESSEX SOUTH DISTRICT REGISTRY OF DEEDS hereby declare that I own, and am possessed of, and occupy said premises as a residence and Homestead as provided in Chapter 188, Section 1, of the Massachusetts General Laws, as amended from time to time.

_____________________________________________________________________________________
TO BE SIGNED BY APPLICANT IN FRONT OF NOTARY PUBLIC:

Witness my hand and seal this __________ day of ___________________ , 20

__________________________________________________________________________
FOR USE BY PUBLIC ONLY:

COMMONWEALTH OF MASSACHUSETTS

      On this ______ day of __________, 20            , before me, the undersigned notary public, personally appeared ____________________________________________________, proved to me through satisfactory evidence of identification, which were ________________________________________, to be the person whose name is signed on the preceding or attached document and acknowledge to me that he/she signed it voluntarily for its stated purpose.

FILING FEE:

$35.00 *Includes all surcharges

Make checks payable to: Commonwealth of Massachusetts

If mailing, send to:

John L. O'Brien, Register of Deeds Essex South District Registry of Deeds 36 Federal Street Salem, MA 01970