DECLARATION OF HOMESTEAD

I,   _____________________________________________________________

owning and occupying the premises at ________________________________________________

located in _________________________________________, Massachusetts.

the deed being recorded in Book _________, Page _______ in the SOUTHERN ESSEX DISTRICT REGISTRY OF DEEDS

OR

as Certificate of title number ______________ registered in the Land Registration Office of the SOUTHERN ESSEX 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.

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

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

Witness my hand and seal this __________ day of __________________ , 20 __

____________________________________________________________________________
FOR USE BY NOTARY 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.

If mailing, send to:

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