State of , County
I, , an individual residing at (the "Testator"), declare this to be my codicil (the "Codicil") to my Last Will and Testament (the "Will") created by me on . I declare that I am of legal age and sound mind that this Codicil expresses my wishes without undue influence or duress.
My Will shall be amended and modified to change the following:
All other terms, conditions, statements, and requests of the Will shall remain in effect. In every respect, I hereby ratify, reaffirm, and republish my Will dated .
IN WITNESS WHEREOF, I, the Testator, have authorized this Codicil on the undersigned date and in the presence of two witnesses and a notary public.
Signature: ________________________________
Printed name:
Witness Acknowledgment
On the date last above written, , known by us to be the person whose signature appears at the end of this Codicil, declared to us, and , the undersigned, that the foregoing instrument was the Codicil to the Will dated ; who then signed the Codicil in our presence, and now, in the presence of each other, we sign our names as witnesses.
Witness 1
Signature: ________________________________
Printed name:
Witness 2
Signature: ________________________________
Printed name:
State of
Acting in the county of
Sworn to and subscribed before me on ___________________________.
___________________________________
Place for signature
______________________________________
Notary public's name and seal