OMISSION OF FORMER SPOUSE

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

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

____________________________________ (Name), of ______________________

________________________________, who was my _________________, until our divorce on ________________________ (Date) has been willfully omitted from my will and shall have no claim to any part of my estate.

____________________________________ _______________

Signature Date

____________________________________ _______________

Witness Date

____________________________________ _______________

Witness Date

___________________________________ _______________

Witness Date