SECTION 255 AFFIDAVIT

(Reverse Mortgage)

State of _____________ }
County of ___________ }ss:

____________________________ , being duly sworn deposes and says:

1. I am the of ____________________ , the owner and holder of the mortgage which is being submitted for recording. I am familiar with the facts set forth herein.

2. On ______________ , _________________________ executed and delivered to ________________ a mortgage for property located at and known as Tax Lot ____ , in Block _______ on the Tax Map of the ________ of __________, County of _________ , State of New York in the amount of $____________ .

3. The mortgage is a reverse mortgage and complies with the provisions of Section 280 (280A) of the Real Property Law.

4. The mortgagor(s) is (are) over the age of 60 (70) and he/she/they occupy the property as his/her/their principal residence.

5. The mortgage is on real property improved by a one-to-four family dwelling or condominium unit.

6. The deponent respectfully requests that this reverse mortgage tendered herewith for recording be declared exempt from taxation pursuant to the provisions of Section 252-A (2) of Article 11 of the Tax Laws of the State of New York.

______________________________

Sworn to before me this
____ day of _____ , 19 ___..

________________________