PWOS.DOC Page 1 of 1 Docket No.: State of New Jersey Essex County Surrogate222s Court In the matter of the alleged Will of: , Deceased AKA: }WITNESS PROOF OTHER THAN SUBSCRIBING WITNESS PURSUANT TO N.J.S. 3B:3-19 The undersigned was one of the persons present when the testator/rix, , signed the annexed writing which is purported to be the Last Will and Testament and/or Codicil of , the testator/rix. The undersigned further states that the execution was also in the presence of the subscribing witnesses. That at the time of the doing thereof the testator/rix was of sound and disposing mind, memory and understanding as far as this deponent knows and verily believes; that and , the subscribing witnesses were present at the same time with this deponent when said Will was signed by the testator/rix and by them published and declared as for their Last Will and Testament and/or Codicil, and that the said witnesses subscribed their names to said Will and/or Codicil as witnesses in the presence of said testator/rix and of each other and at the request of the testator/rix and said deponent also being present having knowledge of the facts relating to the proper execution of the Will and/or Codicil by the testator/rix and its attestation by the witnesses. Signature Sworn and subscribed before me on: // A Notary Public of the State of My Commission Expires: Affix Seal American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE DEPUTY SURROGATE Hall of Records, Room 206 Newark, New Jersey 07102 Phone: 973-621-4900 Fax: 973-621-264