Docket No.: _____________ Essex County Surrogate's Court THEODORE N. STEPHENS II SURROGATE Hall of Records, Room 206 Newark, New Jersey 07102 Phone: 973-621-4900 Fax: 973-621-2654 DEVERO D. MCDOUGAL DEPUTY SURROGATE State of New Jersey In the matter of the Estate of: ______________________________________________, Deceased AKA: ________________________________________ STATE OF NEW JERSEY COUNTY OF ESSEX } PROOF OF WITNESS OF CODICIL }SS. I, ________________________________, being of full age and duly sworn upon my oath depose and say: I am one of the subscribing witnesses to the purported Codicil to the Last Will and Testament of the above named decedent. Said decedent willingly signed said writing in my presence, after which I subscribed my name as witness. Said testator/rix was at said time over eighteen (18) years of age, of sound mind and under no constraint or undue influence so far as I know and believe. Signature I, _________________________________________________________, the undersigned authority, do hereby certify in the manner in which such acts are usually authenticated by me that ________________________, the person named in the within Commission, personally appeared before me at _________________________ this ________________________ and was duly sworn by me to the truth of the above deposition signed by same. Sworn and subscribed before me on: ______/______/______ A Notary Public of the State of ____________________________ My Commission Expires: _____________________ Affix Seal 11 PROOF OF WITNESS OF CODOCIL Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com