Codicil form

I, (full name)

of (Address)

Postcode

Declare this to be a (first/second/third) Codicil to my Will dated D D / M M / Y Y Y Y

day/month/year
I give to Samaritans, registered charity in England and Wales 219432 and in Scotland
SC040604, of The Upper Mill, Kingston Road, Ewell, KT17 2AF
the cash sum of £ (pecuniary gift)

my specific gift of (specific gift)

to be used for its general charitable purposes and I direct that the receipt of the treasurer
or
duly authorised officer shall be a sufficient discharge to my executors.
In all other respects I confirm my Will and any previous Codicils thereto.
Signature
Date
D D / M M / Y Y Y Y

Please ensure that you sign this form in the presence of two independent witnesses.

Signed by the person mentioned above, in our presence, and witnessed by us in

the
presence of him/her and of each other.
First witness

Address

Postcode Occupation

Signature D D / M M / Y Y Y Y
Date

Second witness
Name

Address

Postcode Occupation

Signature
Date D D / M M / Y Y Y Y