On the date written below, __________________________________ declared to us,
the undersigned, that this instrument, consisting of these few pages including the page
signed by us as witnesses, was his or her Will and requested us to act as witnesses to it.
He or she thereupon signed this Will in our presence, all of us being present at the same
time. We now, at his or her request, in his or her presence and in the presence of each
other, subscribe our names as witnesses. Each states that the testator is not a minor and
appears to be of sound mind and that we have no knowledge or any facts indicating that
the foregoing instrument, or any part of it, was procured by duress, menace, fraud or
undue influence. We, each for himself or herself, declare that each of us is at least the
age of majority, and that each of us is, and the others appear to be of sound mind. We,
each for himself or herself, declare under penalty of perjury that the foregoing is true
and correct and that this attestation and this declaration are executed on the _________
day of ____________ (month), _____(year) at ________________________________.
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