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I, [name], domiciled at [address] (Testator), declare this writing to be a codicil to my Will, dated [date].
1. In [clause to be changed or revoked], I bequeathed [property given] to [beneficiary].
2. I now revoke that bequest and declare and direct [change to be made].
3. I ratify and confirm my Will in all other respects.
This codicil to the Will of [name] (Testator) was signed and declared by him on [date] in our presence. We have subscribed our names at his request, in his presence, and in the presence of each other, as witnesses to this codicil.
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]