AFFIDAVIT OF WITNESS PURSUANT TO G.L. c. 190B, §§ 2-502, 3-405 Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Date of Death: I, First Name M.I Last Name being duly sworn, do depose and declare that in the presence of First Name M.I Last Name (date) witnessed the above named Decedent either willingly sign an instrument(s) dated or willingly direct another person to sign said instrument(s) in his or her conscious presence, or acknowledged said instrument(s) as and for Decedent's last Will and Testament or codicil(s) and to the best of my knowledge, the Decedent was 18 years of age or older, of sound mind, and under no constraint or undue influence. SIGNED UNDER THE PENALTIES OF PERJURY I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief. Date Signature of Witness Do not write below this line for Court use only Subscribed and sworn to this date (date) . Justice-Assistant-Judicial Case Manager-Assistant Register-Magistrate of the Probate and Family Court American LegalNet, Inc. www.FormsWorkFlow.com MPC 480 (3/19/12) AFW