STATE OF -----------)

) s.s.:

COUNTY OF ----------)

This day personally appeared before the undersigned authority [three names], who, having been first duly sworn, did depose and say:

They are the same persons who subscribed their names as witnesses to the annexed Will [omitted] of [name of Testatrix], dated [date]; Testatrix signed and acknowledged the writing here annexed as and for her Will in their presence; at the time, Testatrix was of sound and disposing mind and memory and over the age of eighteen years; at the request of Testatrix, they signed their names to the writing in the presence of Testatrix and in the presence of each other, as attesting witnesses; and they are making this affidavit at the request of Testatrix, to be offered in evidence when the Will is presented for probate.

[three signatures]

Taken, subscribed, and sworn to before me this [date]. My commission expires on [date].

[signature]

Notary Public [county, state]