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201606370 <br />it is my will, that I sign it willingly, that I execute it as my free and voluntary act for the <br />purposes expressed, and that I am of the age of majority or otherwise legally empowered <br />to make a will and under no constraint or undue influence. <br />Signature <br />Witnesses <br />On this day of <br />, declared to us, the undersigned, that this instrument was his <br />or her will and requested us to act as witnesses to it. The testator signed this will in our <br />presence, all of us being present at the same time. We now, at the testator's request, in the <br />testator's presence and in the presence of each other, subscribe our names as witnesses <br />and each declare that we are of sound mind and of proper age to witness a will. We <br />further declare that we understand this to be the testator's will, and that to the best of our <br />knowledge the testator is of the age of majority, or is otherwise legally empowered to <br />make a will, and appears to be of sound mind and under no constraint or undue influence. <br />We declare under penalty of perjury that the foregoing is true and correct, this 4 <br />day of ' , 20 1_5 , at GA F State of <br />7 r 1Qk Z-uce <br />Typed or printed name <br />log is-I-DD 5 +-a1 I NC <br />Street address, city r County, state <br />/qi/6 Za <br />Witness's signature Typed or printed name <br />9 eAgr b' s'r / /) Et/ ISMS A <br />Street address, city County, state <br />, 2015 , the testator, <br />Will Form 3. Single, Divorced, or Widowed With Child(ren) Page 6 of 6 <br />