I, __________, of __________ County, State of __________, declare this to be the First Codicil to my Last Will and Testament dated __________.

Changes

__________

Confirmation

In all other respects, I confirm and republish my Will.

Witness Attestation

We, the undersigned witnesses, each being at least eighteen (18) years of age, declare that __________ signed this document in our presence, appeared to be of sound mind and under no duress, and that we signed as witnesses in the presence of __________ and of each other. Neither of us is a beneficiary under this document.

Witness 1 Name and Address: ____________________________________________

Witness 2 Name and Address: ____________________________________________