I, ______________________________________ of _____________________________
Massachusetts hereby state and declare as follows:
1) That I am the owner of a home and property known as ___________________,________________, Massachusetts more particularly described in a deed recorded with the _______________County Registry of Deeds in Book _____ Page________ or the ____________________County Registry District of the Land Court as Document __________ and noted on Certificate of Title_______________ and benefitted by this homestead.
2) If checked here [ ], that I have a non-titled spouse whose name is _______________________________
3) That I am ( check applicable)
a. [ ] an Elderly Person as defined by MGL Chapter 188 § 1
b. [ ] a Disabled Person as defined by MGL Chapter 188 § 1 (Note : If selected a an original or certified copy of a disability award letter from the United States Social Security Administration or Physicians Statement must be attached to this Declaration)
4) That I occupy or intend to occupy the said home and property as my principal residence.
5) That I hereby declare a homestead in said home and property under the provisions of MGL Chapter 188, § 2.
Signed under the penalties of perjury this day of__________, 20__________
COMMONWEALTH OF MASSACHUSETTS
On this ___________day of ______________, 20________, before me, the Undersigned notary public, personally appeared the above named __________________________________, proved to me through satisfactory evidence of identification, which was/were _____________________, to be the person whose name is signed on the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his/her knowledge and belief.
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