IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my seal
at __________________, County of Lake, State of Florida, this _____day of ______________,
A.D. _____________.
________________________________________
(Testator or Testatrix)
WE, THE UNDERSIGNED, do hereby attest and certify that the above and foregoing
particular instrument, consisting of two (2) pages, was subscribed and sealed on the date last
above written by said ________________________________ in our presence, and at the same
(Testator or Testatrix)
time was acknowledged and declared by him or her, to each of us to be his or her CODICIL to
his or her LAST WILL AND TESTAMENT, and we, at his or her special instance and request,
and in his or her presence, and in the presence of each other, do attest as witnesses and have
signed our names as witnesses hereto, and written opposite our names our respective places of
residence, after said Testator or Testatrix had signed his or her name thereto, believing the said
______________________________________ to be, at the time of so subscribing our names as
(Testator or Testatrix)
witnesses as aforesaid, of sound and disposing mind and memory.
____________________________________ OF ____________________________________
(Witness Name)
(Witness City, State)
____________________________________ OF ____________________________________
The testator or testatrix may want to review this document with their
attorney if there are any questions. This form may not be acceptable
for wills in states other than Florida.