CODICIL TO THE LAST WILL AND TESTAMENT OF

________

I, ________ (the “Testator”), residing at ________, in the City of ________, County of ________, State of ________, being of the age of eighteen (18) years or older and of sound mind and memory, and not acting under any duress, fraud, menace, or undue influence of any person whomsoever, do hereby make, publish, and declare this to be the ________ Codicil (my “Codicil”) to my Last Will and Testament dated ________ (my “Last Will”).

§ 1. Intent and Confirmation. I expressly affirm that I have read and understand the terms of my Last Will and that, except as specifically amended, modified, or revoked by this Codicil, all of the provisions of my Last Will shall remain in full force and effect. This Codicil shall be read and construed together with my Last Will as a single integrated testamentary instrument.

§ 2. Additional Provision. My Last Will is hereby amended to include the following additional provision:

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§ 3. Deletion of Provision. My Last Will is hereby modified by deleting and revoking the following provision in its entirety:

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§ 4. Revision of Provision. My Last Will is hereby modified as follows. The following portion of my Last Will is hereby revoked:

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and is replaced with the following text:

________

§ 5. No Revocation of Prior Codicils Except as Stated. Except to the extent expressly inconsistent with the provisions of this Codicil, I do not revoke any prior valid codicil to my Last Will, and any such prior codicil shall continue in effect to the extent not superseded hereby.

§ 6. Republication. I hereby ratify, confirm, and republish my Last Will dated ________ in every respect other than those expressly amended, modified, or revoked by this Codicil, and I declare that my Last Will, as so amended by this Codicil, expresses my testamentary intent.

§ 7. Governing Law. This Codicil shall be governed by, construed, and administered in accordance with the laws of the State of ________.

§ 8. Severability. If any provision of this Codicil is held to be invalid, void, or unenforceable, the remaining provisions shall nevertheless continue in full force and effect.

IN WITNESS WHEREOF, I have hereunto set my hand to this Codicil to my Last Will and Testament on this ________ day of ________, ________, in the City of ________, State of ________, declaring and publishing this instrument as my Codicil to my Last Will, in the presence of the undersigned witnesses, who witnessed and subscribed this Codicil at my request, and in my presence.

______________________________________
________, Testator

SIGNED, PUBLISHED, AND DECLARED by ________ on this ________ day of ________, ________, as and for the Testator's Codicil to Last Will, in the presence of us, who, at the Testator's request, in the Testator's presence, and in the presence of each other, have subscribed our names as witnesses on the date written above. We declare that, to the best of our knowledge, the Testator is eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence.

___________________________
Witness #1 Signature

___________________________
Witness #1 Printed Name

___________________________
Witness #1 Street Address

___________________________
Witness #1 City, State

___________________________
Witness #2 Signature

___________________________
Witness #2 Printed Name

___________________________
Witness #2 Street Address

___________________________
Witness #2 City, State

SELF-PROVING AFFIDAVIT

STATE OF ________

COUNTY OF ________

I, ________, the undersigned Testator, do hereby declare to the undersigned authority that I sign (or direct another to sign for me) and execute this instrument as my Codicil to my Last Will, that I sign it willingly (or willingly direct another to sign it for me) in the presence of each of the witnesses named below, that I execute it as my free and voluntary act for the purposes herein expressed, and that I am eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence.

______________________________________
________, Testator

We, the undersigned witnesses, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed (or directed another to sign for the Testator and that person signed for the Testator) and executed this instrument as the Testator's Codicil to Last Will in the presence of each of us, that the Testator signed it willingly (or willingly directed another to sign it for the Testator), that each of us hereby signs this Codicil as witness in the presence of the Testator and of each other, and that to the best of our knowledge the Testator is eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence.

______________________________________
Witness #1 Signature

______________________________________
Witness #2 Signature

Subscribed, sworn to, and acknowledged before me by ________, the Testator, and subscribed and sworn to before me by ________ and ________, witnesses, this ________ day of ________, 20________.

(seal)

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___________________________
(Printed name of officer)

___________________________
(Official capacity of officer)

My commission expires: ________