THIS CODICIL DATED ________________ [insert date of codicil] is the [first/second/etc] codicil to the
Last Will and Testament of me, [NAME OF TESTATOR], of [street address], [city], [state or
territory], [occupation], which Will is dated ______________.
I HEREBY amend my said Will as follows:
1. [list the revisions to be made to the Will]
In all other respects I hereby confirm my said Will.
IN TESTIMONY WHEREOF I have hereunto subscribed my name this _____ day of ____________,
Signature of Testator
SIGNED, PUBLISHED AND DECLARED by the said Testator, [INSERT YOUR FULL NAME], as
and for his/her Last Will and Testament, in the presence of us, both present at the same time, who at
his/her request, in his/her presence and in the presence of each other, have hereunto subscribed our
names as witnesses.
Signature of Witness Signature of Witness
Print Name of Witness