DECLARATION OF HOMESTEAD



[THREE INCH TOP MARGIN]DECLARATION OF HOMESTEADM.G.L. c. 188 § 3 (For Homes Owned by Trustee(s))I (We) ___________________ (and _______________________) Trustee(s) of the (Trustee 1) (Trustee 2)______________________ Trust u/d/t dated _____________, hereby declare homestead pursuant to M.G. L. c. 188 § 3, for the benefit of the beneficiaries hereinafter named with respect to the herein-described premises and state as follows:Said Declaration of Trust is [ ] recorded in ____________ Registry of Deeds in Book _____, Page ______[ ] filed in the ______________________ Registry District of the Land Court as Document No. _______[ ] described in a Trustee’s Certificate under M.G.L. c. 184, §35:[ ] recorded in said Registry of Deeds in Book _____, Page ______[ ] filed in said District as Document No. _______[ ] Other [describe derivation]:__________________________________________I am the owner/We are the owners as Trustee(s) of the premises at _________________________________________, by virtue of:[ ] deed from __________________ dated __________ and recorded in said Registry of Deeds in Book _____, Page ______[ ] Certificate of Title No. _______ in said District[ ] the Will of __________, _________ Probate Case No. __________[ ] Other [describe document and provide appropriate recording/registration/court docket information]: __________________________________________________which premises __________________________ (and) ________________________, as (Beneficiary 1) (Beneficiary 2)beneficiary(ies) of the trust, occupy(ies) or intend(s) to occupy as his/her/their principal residence.Beneficiary(ies) ____________________(and) ________________________ is/are:(Beneficiary 1) (Beneficiary 2)[ ] unmarried[ ] married to each other[ ] married to _____________________, who is a co-beneficiary of the trust and:REBA Form No. 16A[ ] who also occupies or intends to occupy the premises as his/her principal residence and who has the benefit of a declaration of homestead under M.G.L. c. 188, § 2 recorded/filed with said Registry of Deeds/District: [ ] in Book ______, Page ___/as Document No. _______[ ]herewith[ ] who does not occupy or intend to occupy the premises as his/her principal residence[ ] married to _____________________, who is not a co-beneficiary of the trust and:[ ] who also occupies or intends to occupy the premises as his/her principal residence.[ ] who does not occupy or intend to occupy the premises as his/her principal residence.Beneficiary ________________ [ ] is / [ ] is not and Beneficiary _________________ (Beneficiary 1) (Beneficiary 2) [ ] is / [ ] is not a servicemember who may be entitled to protection under the Servicemembers Civil Relief Act, 50 U.S.C. 553, should he/she be called to active duty.Signed under the penalties of perjury this ______________ day of __________________, 20____. __________________________________________ (Trustee 1) __________________________________________ (Trustee 2)COMMONWEALTH OF MASSACHUSETTSOn this ______ day of _____________, 20_____, before me, the undersigned notary public, personally appeared _________________________________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were ___________________________________, to be the person who signed the preceding or attached document in my presence, 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.____________________________________(official signature and seal of notary)My commission expires: _______________REBA Form No. 16ACommentsIf the home is held in trust, then the declaration of homestead:must be signed by the trustee(s),must set forth the name of each beneficiary who occupies or intends to occupy the premises as his/her principal residence,must set forth the name of the spouse, if any, of each resident beneficiary, andmust state whether the resident beneficiary’s spouse also occupies or intends to occupy the premises as his or her principal residence. If the resident beneficiary’s spouse lives elsewhere, the address of the resident beneficiary’s spouse does not need to be set forth.When there are more than two trustees and/or more than two beneficiaries, Form 16A can be modified to identify each additional trustee and/or beneficiary. See M.G.L. c. 188, as amended by Chapter 395 of the Acts of 2010 (Approved December 16, 2010) (Effective March 16, 2011)Adopted May 2, 2011Amended May 6, 2013 (to identify trustees and beneficiaries, to reflect enactment of G.L. c. 188, § 5(e) by c. 108 § 15 of the Acts of 2012 by insertion of Section 4, and to add Comment 2) REBA Form No. 16A ................
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