I/We, _____________________________________________, owning and occupying as a principal residence the real estate at ______________________________, in _________________ Massachusetts

____ being 62 years of age or older
____ being physically or mentally disabled, evidenced by the attached certification, and  because of such disability, not able to engage in substantial gainful employment.

Ownership Evidenced by:

____Deed from ____________________________________dated ___________and

recorded in _______________ Registry of Deeds in Book________ Page_______ .

____Certificate of Title #__________________ registered in _______________ County Land Court. Shown as Lot: _______, On Land Court Plan _______.

____Inheritance from_____________________________________________, Probate Court Docket #:____________, __________ County Probate Court.

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

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(s) who executed the foregoing instrument and acknowledged the same to be_______ free act and deed, before me,

____________________________________
Notary Public
My commission expires: . . . . . . . . . . . . . . . .