I, ________________________________________, owning and occupying as my

principal residence the real estate at______________________________(Street address),

____Deed from ____________________________________dated ___________and

recorded in Book________ Page________ .

____Certificate of Title #__________________ registered in the _______________ Registry of Deeds Land Court.

____Inheritance from__________________________________________________ ,

_________________________Probate Court Docket #______________________.
(County Probate Court)

hereby declare a Homestead in said premises under the provisions of Chapter 188, Section 1 of the General Laws of Massachusetts.

I expressly reserve the right, to myself and my spouse and to the survivor of us, and to the Executor or Administrator of the survivor of us, to revoke and rescind this Homestead as to ourselves and our minor, unmarried children.

Executed as a sealed instrument this_________day of ___________________20____.

 ___________________________________

COMMONWEALTH OF MASSACHUSETTS

_________________________, ss . . . . . . . . . . . . _________________________, 20__

Then personally appeared the above-named _________________________________
known to me to be the person who executed the foregoing instrument and acknowledged the same to be_______ free act and deed, before me,