STATEMENT OF NON-INDEBTEDNESS TO LEGATEES

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

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

I state and believe that at the time of my death, I am in no way indebted to any of the legacies of my will. Should any of my legatees claim a debt from my estate, my executor shall pay that amount upon verification, but then decrease such legatees’ amount of claim in my property by that same amount.

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Signature Date

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Witnessed Date

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Witnessed Date

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Witnessed Date