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 the instrument on file in this court dated
_______________________, is the last will and testament of
_______________________________ which __________________________
witnessed. 

2.  That _______________________________ signed this instrument in
their presence. 

3.  That _______________________________ is well known to
_______________________________, and that at the time of execution
__________________________ believes
_______________________________ to be of lawful age, of sound mind
 and under no undue influence or constraint. 


______________________________________________________________ 
__________________________ 


______________________________________________________________ 
Officer