Know All Men by These Presents: That I do hereby certify and declare that I am married and that I do now, at the time of making this declaration, actually reside with my family on the land and premises hereinafter described. That my family consists of a wife and ...............

children. That the land and premises on which I reside are bounded and described as follows, to-wit: Lying and being in the ....................

County of ...........................State of...................., and particularly described as follows:

(Description.)

That it is my intention to use and claim the said lot of land and premises above described, together with the dwelling-house thereon, and its appurtenances, as a Homestead, and I do hereby select, declare and claim the same as a Homestead;

That my wife has not made any declaration of homestead on said lands and I therefore make this declaration for the joint benefit of myself and wife.

That the actual cash value of said property I estimate to be $.........

In Witness Whereof, I have hereunto set my hand and seal, this ...................day of..................., one thousand nine hundred

.............................(Seal)

Signed, Sealed and Delivered in the Presence of

( Acknowledgment.)