_______________________________________ [INSERT YOUR FULL NAME], of
______________________________________________________ [give full address],
declare this to be a Codicil to my Will dated the _____ day of ______________, _______.
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 WITNESS WHEREOF I have hereunto set my hand this _____ day of ____________,
Signature of Testator
SIGNED by ____________________ [INSERT YOUR FULL NAME], 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 Print