Record and Return to: 1) EDIT WHAT IS IN BLUE TO FIT YOUR SITUATION.

First:Last 2) SELECT ALL THE TEXT, CHANGE COLOR TO BLACK.

c/o P O Box XXXXX 3) DELETE THIS TEXT, SAVE FILE, PRINT AS NEEDED.
City, Ohio; [zip in these brackets]

SPACE ABOVE FOR RECORDER USE

Notice / Declaration of Homestead

To Whom it may concern;

You are notified that the undersigned, _______________________, a man/woman in the flesh that the
blood does flow and the air is breathed, do hereby claim his/her homestead under Article I of the
Constitution of the State of Ohio as being the following described real property:

Situated in the City/Town of .........[get this from county or your copy, it's part of your
deed]............of _________ County Records and bounded and described as follows:

Parcel No. XXX

Being a parcel of land lying on the south/north/west/east/erly side of XXXXXX Avenue/Street/

Lane and being located within the following described points in the boundary thereof:

Commencing at a monument found on the right-of-way centerline ..........[survey description -

usually in legal description on deed too].......... to the true place of the beginning.

Parcel Number: xxx-xx-xxx

Physical Address: house number Avenue, City, Ohio; [zip]

The undersigned, First:Last hereby certifies, by affirmation, that he/she has declared the above
described real property to be his/her permanent domicile continuously and uninterrupted from/since the
XXth day of Month, Year to the date of this Homestead Notice and do hereby declare that he/she intend
the above described real property to be his/her predominate and permanent domicile, having been in
full possession of same since such date. Further, the undersigned does not know of any judgment lien
or encumbrance with repect to the above described real property that has any standing within the laws
of the Constitution for the State of Ohio and the Constitution for the united States of America.

Additionally, the undersigned for the purposes of this filing, hereby do declare and certify that in all
commerce he/she conducts, and in relation to the above described real property, the dollar is defined as
set by the United States Mint for an American Silver Eagle dollar coin which contains one ounce of .
999 fine silver, lawful specie, money, as defined by the Constitution for the united States which bears
no debts, for all lawful purposes.

With dollar herein defined, the undersigned, hereby makes claim his/her homestead exempt /
excluded from levy and execution under Article XII of of the constitution of the State of Ohio.

You are further notified, pursuant to Ohio Revised Code Sections 2329 et seq., 5301 et seq., 5302 et
seq., and 5303 et seq., that within thirty (30) days after the recording of this Notice of Homestead, you
must file an action in the Court of __________ County, Ohio for a declaratory judgment to determine
the constitutional homestead status of the subject real property or to foreclose your alleged interest on
the real property and record a lis pendens in the public records of the County where the Homestead is
located. Your failure to so act will result in the undersigned or his/her successors and/or assigns under
the above-described Notice/Declaration of Homestead to take and keep free and clear of any judgment
lien you may have alleged on the real property.

___________________________________
First:Last

The above named, First:Last, personally known/by identification shown to me, did appear
before me and did execute this two-page document foregoing on this day of _____________,
2011.

Seal
______________________________
Notary Public