STATE OF -----------)
COUNTY OF ----------)
This day personally appeared before the undersigned authority [three names], who, having been first duly sworn, did depose and say:
They are the same persons who subscribed their names as witnesses to the annexed Will [omitted] of [name of Testatrix], dated [date]; Testatrix signed and acknowledged the writing here annexed as and for her Will in their presence; at the time, Testatrix was of sound and disposing mind and memory and over the age of eighteen years; at the request of Testatrix, they signed their names to the writing in the presence of Testatrix and in the presence of each other, as attesting witnesses; and they are making this affidavit at the request of Testatrix, to be offered in evidence when the Will is presented for probate.
Taken, subscribed, and sworn to before me this [date]. My commission expires on [date].
Notary Public [county, state]