State of Colorado )

)

County of ________ )

We, ______, _______ and ________, the testator/testatrix and the witnesses, respectively,, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator/testatrix signed and executed the instrument as his/her codicil to his/her last will and that he /she executed it as his/her free and voluntary act for the purposes therein expressed; and that each of the witnesses, in the presence and hearing of the testator/testatrix. Signed the instrument as witness and that to the best of his or her knowledge the testator/testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence.

 _________________________

Testator/Testatrix

_________________________

Witness

 _________________________

Witness
 
 

SUBSCRIBED, SWORN TO AND ACKNOWLEDGED before me by ___________, the testator/testatrix, and SUBSCRIBED AND SWORN TO berore me by _____________ and ____________, witnesses, this _____ day of ______, 199_.

My Commission expires ___________.

_________________________

Notary Public