CODICIL TO LAST WILL OF________________________
I, ________________________ (the 'Testatrix') of ______________________, Virginia, declare this to be my codicil to last will (my 'Codicil') to my last will and testament being dated the 28th day of September, 2016 (my 'Last Will').
IN WITNESS WHEREOF, I have signed my name on this the 28th day of September, 2016, at __________, Virginia, declaring and publishing this instrument as my Codicil to Last Will, in the presence of the undersigned witnesses, who witnessed and subscribed this Codicil to Last Will at my request, and in my presence._____________________________________________________ (Testatrix)
SIGNED AND DECLARED by ________________________ on the 28th day of September, 2016 to be her Codicil to Last Will, in our presence, at __________, Virginia, who at her request, in her presence and in the presence of each other, all being present at the same time, have signed our names as witnesses.
__________________________Witness #1 Signature__________________________Witness #1 Name (Please Print)__________________________Witness #1 Street Address__________________________Witness #1 City/State
__________________________Witness #2 Signature__________________________Witness #2 Name (Please Print)__________________________Witness #2 Street Address__________________________Witness #2 City/State
STATE OF VIRGINIACOUNTY/CITY OF _____________________________Before me, the undersigned authority, on this day personally appeared ________________________, ____________________ and ____________________, known to me to be the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument and, all of these persons being by me first duly sworn, ________________________, the Testatrix, declared to me and to the witnesses in my presence that the instrument is the Codicil to Last Will of the Testatrix and that she had willingly signed or directed another to sign the same for her, and executed it in the presence of said witnesses as her free and voluntary act for the purposes therein expressed; that said witnesses stated before me that the foregoing Codicil to Last Will was executed and acknowledged by the Testatrix as her Codicil to Last Will in the presence of said witnesses who, in her presence and at her request, and in the presence of each other, did subscribe their names thereto as attesting witnesses on the day of the date of said Codicil to Last Will, and that the Testatrix, at the time of the execution of said Codicil to Last Will, was over the age of eighteen years and of sound and disposing mind and memory._____________________________Testatrix
Subscribed, sworn and acknowledged before me by ________________________, the Testatrix, and subscribed and sworn before me by ____________________ and ____________________, witnesses, this _____ day of ____________________, A.D. 20_______.SIGNED ___________________________________________________________________(OFFICIAL CAPACITY OF OFFICER)
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