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The Commonwealth of Massachusetts (Town of Nantucket)

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The Commonwealth of Massachusetts
William Francis Galvin, Secretary of the Commonwealth
Declaration of Homestead for Homes Owned
by Trustee(s) (General Laws Chapter 188)
1. I, ________________________________________________________ , Trustee
(insert name of owner)
We, ______________________________________________________________,
(insert name of owners)
__________________________________________________________, Trustees
of certain trust _____________________________________________________
(trust name)
_________________________________________________________________,
dated _______________ and recorded ________________and________________
(date) (book) (page)
hereby declare homestead pursuant to M.G.L. c.188 and state that I/we own the home
described below and which the beneciaries listed herein occupy or intend to occupy
as his/her/their principal residence:
Beneciary Information
2. Enter beneciary name(s): _____________________________________________________________________________________
(insert beneciary name(s))
3. Check all that apply and enter beneciary name(s):
________________________________________________________________________is/are elderly (62 years of age or older).
(insert beneciary name(s))
_____________________________________________________________________________________________________
(insert beneciary name(s))
is/are disabled (have a physical or mental impairment that meets the disability requirements for Supplemental Security Income
under 42 U.S.C. 1382c(a)(3)(A) and 42 U.S.C. 1382c(a)(3)(C). One of the following must be attached: 1) an original or certied
copy of a disability award letter issued to the person by the United States Social Security Administration, or 2) a letter signed by a
physician registered with the board of registration in medicine certifying that each person meets the disability requirements stated
in 42 U.S.C. 1382c(a)(3)(A) and 42 U.S.C. 1382c(a)(3)(C).
4. For each applicable beneciary, complete one statement. Attach additional page(s) as necessary.
__________________________________________ is married to ________________________________________________
who is not a co-owner of the home but who occupies or intends to occupy the home as his/her principal residence.
__________________________________________ is married to ________________________________________________
who is not a co-owner of the home but who occupies or intends to occupy the home as his/her principal residence.
Home Information
5. Address: ______________________________________________________________________________________ , Massachusetts.
(street number and name, city/town)
6. Select ONE of the following:
Deed is recorded in __________________________________ Registry of Deeds in ______________ and _______________
(district/county) (book) (page)
Certicate of Title _________________ registered in the Land Registration Oce ______________ and _______________
(number) (book) (page)
Inheritance from _________________________________________________________________________ , Docket number
(name of previous owner)
_______________________________________________ in ________________________________________________.
(number) (county)
For manufactured homes, license number __________________________________________________________________ .
(number)
Filing Fee $35
(over)
Declaration of Homestead for Homes Owned by Trustee(s) - Page 1 of 2
7. I/we, the trustee(s) whose name(s) are signed on this document, acknowledge that I/we sign it voluntarily for its stated purpose.
To be signed by Applicant(s) in front of Notary Public.
Signed under pains and penalties of perjury this
_______________________________________________day of _____________________________________________ , 20 ______.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
For Use by Notary Public Only:
COMMONWEALTH OF MASSACHUSETTS
_______________________________________________, ss.
________________________________________, 20 ______ , before me, the undersigned notary public, personally appeared
____________________________________________________________________________________________________ ,
(name(s) of the document signer(s))
proved to me through satisfactory evidence of identication, which were ___________________________________________ ,
(drivers license, passport, etc.)
to be the person(s) who signed the preceding or attached document in my presence, and who swore or armed to me that the contents of
the document are truthful and accurate to the best of (his) (her) (their) knowledge and belief.
Notary Public: ____________________________________________________________________________________________
My commission expires: _____________________________________________________________________________________
Declaration of Homestead for Homes Owned by Trustee(s) - Page 2 of 2
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The Commonwealth of Massachusetts (Town of Nantucket)

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Completed 14 July 2020

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