TWO UNIT HOUSE DECLARATION

Address of Property with Two Unit House_____________________________________

Dwelling Type: ÿ Detached House ÿ Semi-Detached House ÿ Rowhouse

Two Unit House means a detached house, semi detached house and rowhouse

containing two residential units with each unit:

· consisting of a self contained set of rooms located within a residential structure;

· used as a residential premise;

· containing kitchen and bathroom facilities designated for the exclusive use of its occupants; and

· having a means of egress to the outside of the building or structure in which it is located, which may be a means of egress through another residential unit.

I, ________________ OF DO SOLEMNLY DECLARE THAT:

(name of declarant) (address of declarant)

1. Two residential units were in existence on the property at the above noted property on November 16, 1995.

2. On _______________I was:

(day/month/year)

ÿ the registered owner of the property with the two unit house

ÿ the tenant of the second residential unit

ÿ the contractor who completed the construction of the second residential unit

ÿ the lawyer involved with the title history search for the property with the two unit house

ÿ the mortgage holder who dealt with mortgage for the property with the two unit house

ÿ the insurance broker who dealt with policy for the property with the two unit house

ÿ the independent property assessor who assessed the property with the two unit house

ÿ the real estate agent involved with previously listing the property with the two unit house

 other _____________________________________________________

(give details)

3. In support of this declaration I am submitting one or more of the following pieces of evidence as further proof of the existence of the two unit house at the above noted property on November 16, 1995:

ÿ a cancelled rent cheque or receipt for cheque for the two unit house

ÿ a lease or rental contract for the two unit house

ÿ an income tax return showing source of income from the two unit house

ÿ a utility bill or meter hook up for gas, hydro, phone service related to the two unit house

ÿ a receipt for contractor’s service charge for construction of the second residential unit

ÿ a photograph, video or real estate listing of the two unit house with date reference

ÿ a Town record of permit and/or inspection of the two unit house either by request or complaint

ÿ other ____________________________________________________

(give details)

AND I MAKE THIS SOLEMN DECLARATION CONSCIENTIOUSLY BELIEVING IT TO BE TRUE, AND KNOWING THAT IT IS OF THE SAME FORCE AND EFFECT AS IF MADE UNDER OATH

DECLARED BEFORE ME at the ____________________________________

__________ of ____________, Signature of Declarant

in the __________of _________, this ____________________________________

_____ day of __________, 200_____. Print Name of Declarant

_______________________________

A Commissioner for taking affidavits, etc.