Introductory Clause.  I, (Insert Name), do hereby make, publish and declare this to be a Codicil to my Last Will and Testament dated ________________.

First

I do hereby amend my Last Will and Testament, dated ______________, by adding thereto the following:
I give and bequeath to _________________(Insert name of charity) the sum of $_____________.

Fourth

I hereby republish and reaffirm my Last Will and Testament as herein modified, amended and supplemented by this Codicil as if such Will were set out here in full and do incorporate it by this reference thereto, and do herby republish and declare my Last Will and Testament as amended, modified and supplemented as my Last Will and Testament.

Testimonium Clause.  INWITNESS WHEREOF, I herewith set my hand and seal to this Codicil to my Last Will and Testament, this _____ dayof ____________, ____(year).

___________________(Seal)
(Insert Name)                 

Attestation Clause.  The foregoing Codicil was signed, sealed, and acknowledged in our presence by the Testator/Testatrix this ______day of ____________, ____(year) as and for a Codicil to his/her Last Will and Testament and thereupon we, at his/her request and in his/her presence, and in the presence of each other, have hereunto subscribed our names as witnesses on the above date.

_______________________of_______________________
_______________________of_______________________

SELF PROVING AFFIDAVIT

Commonwealth of Virginia
City of ______________

Before me, the undersigned authority on this day personally appeared ________________ (Insert name of Testator/Testatrix), and ___________________ and ___________________ (Insert names of witnesses) known to me to be the Testator/Testatrix and the witnesses, respectively, whose names are signed to the attached foregoing instrument, and all of these persons being me first duly sworn, the Testator/Testatrix declared to me and to the winesses in my presence that said instrument is a Codicil to his/her Last will and Testament and he/she has willingly signed the same and executed it in the presence of said witnesses as his/her free and voluntary act for the purposes therein expressed; that said witnesses stated before me that the foregoing Codicil was executed and acknowledged by the Testator/ Testatrix as a Codicil to his/her Last Will and Testament in the presence of said witnesses who, in his/her presence and at his/her request, and in the presence of each other, did subscribe their names thereto as attesting witnesses on the day of the date of said Cadicil, and that the Testator/Testatrix, at the time of the execution of said Will, was over the age of eighteen years and of sound and diposing mind and memory.

Sworn and acknowledged before me by the above named Testator/testatrix and witnesses, this _______day of _____________, ___(year). My commission expires ______________.

______________________
Notary Public