Fillable Commonwealth of Massachusetts Transfer of Ownership - Buyer

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Commonwealth of Massachusetts Transfer of Ownership - Buyer

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The Commonwealth of Massachusetts Transfer of Ownership - Buyer form is 2 pages long and contains:

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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The Commonwealth of Massachusetts
Executive Office of Elder Affairs
One Ashburton Place, 5th Floor
Boston, Massachusetts 02108
Transfer of Ownership Notification
In accordance with the Massachusetts Assisted Living Regulations 651 CMR 12.03(8), the
application for a Change of Ownership must include a statement signed and notorized by the
parties, regarding the anticipated transfer of Ownership of the Residence.
Assisted Living Residence (ALR) to be transferred:
_____________________________________________________________________
ALR Name
_____________________________________________________________________
Address
_____________________________________________________________________
City/ Town Zip code
The undersigned representative of the applicant confirms the intent of the buyer to purchase the
ownership entity of the above named ALR from:
_________________________________________________________________________
The anticipated date of the transfer is: _________________________________
BUYER:
______________________________________________________
Name of proposed ownership entity
____________________________________________________________
Signature of Person Authorized to sign for Applicant (Officer, Trustee or Individual)
____________________________________________________________________
Print Name & Title of Person Authorized
Change of Ownership - Buyer
Page 2 of 2
Notary Signature and Seal:
On this ______day of ___________________________, 20______, the above named individual
proved to me through satisfactory evidence of identification and authorization regarding the
anticipated transfer of ownership of the Assisted Living Residence identified above.
Subscribed and sworn to before me on this _________day of ____________ 20_________.
My Commission expires: _______________________________________ 20_________.
________________________________ (Seal)
Notary Public
Page 2 of 2
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Commonwealth of Massachusetts Transfer of Ownership - Buyer

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Completed 10 May 2020

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