CODICIL

WHEREAS, on ___________________, I, ___________________, executed

my last will and testament, and;

WHEREAS, I revoked said last will and testament by _______________

__________________________________________________________; and,

WHEREAS, it is now my intention to ratify said will;

I NOW PUBLISH THIS CODICIL to my last will and testament of

___________________:

I ratify and reaffirm said will and confirm that the will

executed on ___________________ is my last will and testament.

Dated: ______________________

________________________________

___________________, TESTATOR

I herewith affix my signature to this codicil on this

the ____________ day of ________________________________, 19___

at ________________________________________, in the presence of

the following witnesses, who witnessed and subscribed this

codicil at my request, and in my presence.

ATTESTATION CLAUSE

On the date above written, ___________________, well known to

us declared to us, and in our presence, that this instrument,

consisting of _____ pages, is a codicil to their last will and

testament, and ___________________, then signed this instrument

in our presence, and at ___________________'s request we now

sign this codicil as witnesses in each other's presence. Further

that ___________________, appeared to us to be of sound mind and

lawful age, and under no undue influence.

Witness:

_______________________________________________________________

Address: ______________________________________________________

Witness:

_______________________________________________________________

Address: ______________________________________________________

Witness:

_______________________________________________________________

Address: ______________________________________________________

STATE OF _______________)

COUNTY OF ______________)

Before me, the undersigned authority authorized to take

acknowledgments and administer oaths, personally appeared:

___________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

who after being having duly sworn or affirmed to tell the truth,

stated:

1. That ___________________ declared this instrument to be a

codicil to their last will and testament to the witnesses.

2. That ___________________ signed this instrument in their

presence.

3. That the witnesses signed as witnesses in the presence of

___________________ and each other.

4. That ___________________ is well known to the witnesses, and

the witnesses believe ___________________ to be of lawful age, of

sound mind and under no undue influence or constraint.

______________________________________________________________

Officer

Title of Officer:__________________________________________

My Commission Expires: _________________________