OMISSION OF PARTICULAR INDIVIDUAL

As codicil and amendment to my will, dated ___________________, and witnessed by

______________________________, __________________________________, and ______________________________, I, ______________________________ declare the following:

I am fully aware that __________________________________________ is my __________________________________ (Relationship) and that I have omitted _________ (him/her) from my will. This is neither unintentional nor an oversight.

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Signature Date

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Witness Date

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Witness Date

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Witness Date