Know All Men by These Presents : That I.....................

do hereby certify and declare that I am married and am the wife of

..........................; that my husband...........................

has not made any declaration of homestead, and I therefore make this declaration for the joint benefit of myself and husband; that I do now, at the time of making this declaration, actually reside with my...............

on the land and premises described as follows, to-wit: Lying and being in the ................. County of................State of..............

and bounded and 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 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.)