Commonwealth of Massachusetts

Declaration of Homestead

Be it known by these presents, that I, ______________________________________________ of

_______________________ (Type or print your city) 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,
being more particularly described in documents relating to Certificate of Title Number _______
“ and, if the foregoing box is checked, I certify that I am at least sixty-two years of age, or, that I
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.
Witness my hand and seal this _______ day of _______, 200 __

_________________________________________
(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:

____________________

____________________

____________________

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